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Full text of "The American journal of the medical sciences"

Property of the 

Lancaster City and County 
Medical Society 



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THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

EDITED BY 

ISAAC HAYS, M.D., 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OF THE 
AMERICAN MEDICAL ASSOCIATION; OF THE AMERICAN PHILOSOPHICAL SOCIETY; OF THE 
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA, 
&C. &C. &C. 

NEW SERIES. 
VOL. XXXII. 




PHILADELPHIA: 
BLANC HARD & LEA. 



1856. 



69458 



Entered according to the Act of Congress, in the year 1856, by 
BLANC HARD AND LEA, 

in the Office of the Clerk of the District Court of the United States in and for the 
Eastern District of the State of Pennsylvania. 




PHILADELPHIA : 
T. K. AND P. G. COLLINS, PRINTERS. 



TO READERS AND CORRESPONDENTS, 
The following works have been received: — 

Memoir on the Cholera at Oxford in the year 1854, with Considerations Sug- 
gested by the Epidemic. By Henry Wentworth Acland, M. D., F. R. S., 
F. R. G. S., etc, F. R. C. P., Physician to the RadclifFe Infirmary, etc. London: 
John Churchill and J. H. & J. Parker. Oxford: 1851. (From the Author.) 
• Digestion and its Derangements: The Principles of Rational Medicine Ap- 
plied to Disorders of the Alimentary Canal. By Thomas K. Chambers, M. D., 
F. C. P., etc. London : John Churchill, 1856. (From the Author.) 

Cours Theorique et Clinique de Pathologie Interne et de Therapie Medieale. 
Par E. Gintrac, Professeur de Clinique Interne et Directeur de l'Ecole de 
Medecine de Bordeaux, &c. &c. &c. Tom. I, II, III. Paris: Germer Bailliere, 
1853. (From the Author.) 

On the Nature, Treatment, and Prevention of Pulmonary Consumption, and 
incidentally of Scrofula, with a Demonstration of the Cause of the Disease. 
By Henry McCormac, M. D. London: 1855. (From the Author.) 

Deux Memoires sur la Physiologie de laMoelle Epiniere lus a l'Academie des 
Sciences le 27 Aout et le 24 Sept. 1855. Par le Docteur E. Brown-Sequard, 
Laureat de l'Academie des Sciences, etc. (From the Author.) 

Recherches Experimentales sur la Transmission Croisee des Impressions 
Sensitives dans la Moelle Epiniere. Par le Docteur E. Brown-Sequard, Lau- 
reat de l'Academie des Sciences. Paris, 1855. (From the Author.) 

Proprietes et Fonctions de la Moelle Epiniere: Rapport sur quelques Expe- 
riences de M. Brown-Sequard, lu a la Societe de Biologie le 21 Juillet, 1855. 
Par M. Paul Broca, Professeur Agrege k la Faculte de Medecine, etc. Paris, 
1855. (From Dr. Brown-Sequard.) 

Recherches Experimentales sur la Production d'une Affection Convulsive 
Epileptiforme a la Suite de Lesions de la Moelle Epiniere. Par le Docteur E. 
Brown-Sequard, Laureat de l'Academie des Sciences, etc. Memoire lu k 
l'Academie des Sciences, le 21 Jan. 1856. (From the Author.) 

These pour le Doctorat en Medecine. Presentee et contenue a la Faculte de 
Medecine de Paris. Par George Henry Brandt, ne a Ponta-Delgada (Sao- 
Miguel-Iles Acores), Docteur en Medecine, Honore d'une Medaille pour le Cho- 
lera en 1849. Paris, 1855. (From Dr. E. Brown-Sequard.) 

Human Physiology. By Robley Dunglison, M. D., LL. D., Professor of the 
Institutes of Medicine in Jefferson Medical College, Philadelphia. "With five 
hundred and thirty-two Illustrations. Eighth edition, revised, modified, and 
enlarged; in two volumes. Philadelphia: Blanchard & Lea, 1856. (From the 
Publishers.) 

New Remedies, with Formulae for their Preparation and Administration. 
By Robley Dunglison, M. D., &c. Seventh edition, with numerous additions. 
Philadelphia: Blanchard & Lea, 1856. (From the Publishers.) 

The Principles of Surgery. By James Miller, F. R. S. E., F. R. C. S.E., 
Author of a Treatise on the Practice of Surgery, Surgeon in Ordinary to the 
Queen for Scotland, etc. Fourth American, from the third and revised London 
edition. Illustrated by two hundred and forty engravings on wood. Philadel- 
phia: Blanchard & Lea, 1856. (From the Publishers.) 

The Dissector's Manual of Practical and Surgical Anatomy. By Erasmus 
Wilson, F. R. S., Author of a " System of Human Anatomy/' The third 
American from the last revised London edition. Illustrated with one hundred 
and fifty-four wood engravings. Edited by William Hunt, M. D., Demonstrator 
of Anatomy in the University of Pennsylvania. Philadelphia : Blanchard & 
Lea, 1856. (From the Publishers.) 

The Microscope and its Revelations. By William B. Carpenter, M. D., 
F. R. S., F. G. S., Examiner in Physiology and Comparative Anatomy in the 
University of London, Professor of Medical Jurisprudence in University Col- 
lege, etc. With an Appendix, containing the Applications of the Microscope 
to Clinical Medicine, etc., by Francis Gurney Smith, M. D., Professor of the 



4 



TO READERS AND CORRESPONDENTS. 



Institutes of Medicine in the Medical Department of Pennsylvania College, 
etc. Illustrated by four hundred and thirty-four engravings on wood. Phila- 
delphia: Blanchard & Lea, 1856. (From the Publishers.) 

Atlas of Cutaneous Diseases. By J. Moore Neligan, M. D., Edin., M. R. I. 
A., Honorary Doctor of Medicine, Trinity College, Dublin, Fellow of the 
King and Queen's College of Physicians in Ireland, etc. etc. Philadelphia: 
Blanchard & Lea, 1856. (From the Publishers.) 

A Practical Handbook of Medical Chemistry. By John E. Bowman, F. C. S., 
Professor of Practical Chemistry, King's College, London. Second American 
from the third and revised London edition, with Illustrations. Philadelphia: 
Blanchard & Lea, 1856. (From the Publishers.) 

The Principles and Practice of Ophthalmic Medicine and Surgery. By T. 
Wharton Jones, F. II. S., Professor of Ophthalmic Medicine and Surgery in 
University College, London, Ophthalmic Surgeon to the Hospital, etc. With 
one hundred and ten Illustrations. Second American edition, with additions, 
from the second and revised London edition. Philadelphia • Blanchard & Lea, 
1856. (From the Publishers.) 

An Analytical Compendium of the Various Branches of Medical Science for 
the use and examination of Students. By John Neill, M. D., Surgeon to the 
Pennsylvania Hospital, Fellow of the College of Physicians, etc., and Francis 
Gurney Smith, M.D., Physician to St. Joseph's Hospital, Fellow of the Col- 
lege of Physicians, etc. A new edition, revised and improved, with three 
hundred and seventy-four Illustrations. Philadelphia : Blanchard & Lea, 
1856. (From the Publishers.) 

On Some Diseases of Women admitting of Surgical Treatment. By Isaac 
Baker Brown, F. 11. C. S. (By Exam.), Surgeon Accoucheur to St. Mary's Hos- 
pital, Vice-President of the Medical Society of London, etc. etc. Illustrated 
by twenty-four wood engravings. Philadelphia : Blanchard & Lea, 1856. 
(From the Publishers.) 

A Practical Treatise on Diseases of the Testis, and of the Spermatic Cord 
and Scrotum. With numerous wood engravings. By T. B. Curling, F. R. S., 
Surgeon to the London Hospital, Lecturer on Surgery at the London Hospital 
Medical College, etc. Second American from the second revised and enlarged 
English edition. Philadelphia, Blanchard & Lea, 1856. (From the Pub- 
lishers.) 

Medical Jurisprudence. By Alfred Taylor, M. D., F. R. S., F. R. C. P., and 
Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. Fourth 
American from the fifth and improved London edition. Edited, with addi- 
tions, by Edward Hartshorne, M.D., one of the Surgeons to Wills' Hospital, 
etc. Philadelphia: Blanchard & Lea, 1856. (From the Publishers.) 

Headaches, their Causes and their Cure. By Henry G. Wright, M. D., 
M. R. C. S. L., L. S. A., Fellow of Royal Medico-Chirurgical Society, Physician 
to the St. Pancras Royal Dispensary. New York: S. S. and W. Wood, 1856. 
(From the Publishers.) London: John Churchill. (From the Author.) 

Cases in Midwifery, with Remarks, by Thomas F. Cock, M. D., Physician to 
the New York Hospital. New York : S. S. & W. Wood, f 1856. 

The Medical Profession in Ancient Times. An Anniversary Discourse de- 
livered before the New York Academy of Medicine, November 7, 1855. By 
John Watson, M. D., Surgeon to the New York Hospital. (Published by order 
of the Academy.) New York, 1856. (From the Author.) 

Eulogy on the Life and Character of Theodoric Romeyn Beck, M. D., LL.D. 
Delivered before the Medical Society of the State of New York. By Frank 
H. Hamilton, M. D. Published by order of the Senate. Albany, 1856. 
(From the Author.) 

The Causes and Curative Treatment of Sterility, with a preliminary State- 
ment of the Physiology of Generation. By Augustus K. Gardner, A.M., 
M. D., Permanent Member of the American Medical Association, Fellow of 
the New York Academy of Medicine, Member of the Massachusetts Medical 
Society, etc. New York: De Witt & Davenport, 1856. 

Remarks on Vesico-Vaginal Fistule, with an Account of a New Mode of 
Suture, and Seven Successful Operations. By N. Bozeman, M. D., of Mont- 
gomery, Ala. Louisville, 1856. (From the Author.) 



TO READERS AND CORRESPONDENTS. 



5 



Essay on Cholera Infantum, for which the prize of the New York Academy 
of Medicine was awarded, March 5, 1856. By James Stewart, M. D., Author 
of a "Practical Treatise on the Diseases of Children." New York, 1856. 
(From the Author.) 

Transactions of the State Medical Society, transmitted to the Legislature 
February 8, 1856. Albany, 1856. 

Proceedings of the Convention and of the Medical Society of the State of 
California, held in Sacramento, March, 1856. Sacramento, Cal., 1856. 

Transactions of the South Carolina Medical Association at the extra meeting 
in Greenwood, July 18, 1855, and at the annual meeting in Charleston, Feb- 
ruary 6, 1856. Charleston, 1856. 

Third Annual Report relating to the Registry and Returns of Births, Mar- 
riages, and Deaths in the State of Kentucky from January 1, 1854 to Decem- 
ber 31, 1854. Frankfort, Ky., 1856. 

Annual Report of the Officers of the Insane Asylum of the State of Califor- 
nia for the year 1855. James Allen, State Printer. 

Thirteenth Annual Report of the Managers of the State Lunatic Asylum at 
Utica. Albany, 1856. 

City Registrar's Report on the Births, Marriages, and Deaths in the City of 
Providence during the year ending December 31, 1855. With an Appendix, 
showing the Mortality of Providence during fifteen years, from 1840 to 1854, 
inclusive. Providence, 1856. 

Thirty-Ninth Annual Report on the State of the Asylum for the Relief of 
Persons Deprived of the use of their Reason. Published by direction of the 
Contributors. Third month, 1856. Philadelphia, 1856. 

Report of the Joint Special Committee on the Census of Boston, May, 1855 ; 
including the Report of the Censors, with Analytical and Sanitary Observa- 
tions. By Joshua Curtis, M. D. Boston, 1856. (From the Author.) 

The following Journals have been received in exchange : — 

Gazette Medicale de Paris. February, March, April, and May, 1856. 

Revue de Therapeutique M6dico-Chirurgicale. Par A. Martin-Lauzer. 
February, March, April, and May, 1856. 

Journal de Medecine de Bordeaux. Redacteur en chef, M. Costes. January 
and February, 1856. 

Moniteur cles Hopitaux. March, April, and May, 1856. 

Archives D'Ophthalmologie. Par M. A. Jamain. Nov. and Dec, 1855. 

Annales Medico-Psychologiques. Par MM. les Docteurs Baillarger Carise 
et Moreau. April, 1856. 

El Porvenir Medico. Periodico Oficial de la Academia Quirurgica Matritense. 
February, 1856. 

Medical Times and Gazette. March, April, and May, 1856. 

Edinburgh Medical Journal. March, April, and May, 1856. 

Association Medical Journal. Edited by Andrew Wynter, M. D. February, 
March, and April, 1856. 

Dublin Medical Press. March, April, and May, 1856. 

The Glasgow Medical Journal. April, 1856. 

Journal of Public Health and Sanitary Review. Edited by B. W. Richard- 
son, M. D. April, 1856. 

The Journal of Psychological Medicine and Mental Pathology. Edited by 
Forbes Winslow, D. C. L. April, 1856. 

The British and Foreign Medico-Chirurgical Review. April, 1856. 

The Dublin Hospital Gazette. April, May, and June, 1856. 

The Medical Chronicle, or Montreal Monthly Journal of Medicine and Sur- 
gery. Edited by W. Wright, M. D., and D. C. MacCallum, M. D. April, May, 
and June, 1856. 

The Boston Medical and Surgical Journal. Edited by Drs. Smith, Mor- 
land, and Minot. April, May, and June, 1856. 

St. Louis Medical and Surgical Journal. Edited by Drs. Linton and Mc- 
- Pheeters. March and May, 1856. 



G 



TO READERS AND CORRESPONDENTS. 



The American Medical Gazette. Edited by D. M. Reese, M. D. April and 
June, 1856. 

New Orleans Medical News and Hospital Gazette. Edited by Drs. Choppin, 
Beard, and Brickell. March, April, and June, 1856. 

Atlanta Medical and Surgical Journal. Edited by Drs. Logan and West- 
moreland. April and May, 1856. 

The Medical Examiner. Edited by Samuel L. Hollingsworth, M. D. April, 
May, and June, 1856. 

The North-Western Medical and Surgical Journal. Edited by N. S. Davis, 
M. D., and H. A. Johnson, M. D. March, April, May, and June, 1856. 

The Cincinnati Medical Observer. Edited by Drs. Mendenhall, Murphy. 
and Stevens. April, May, and June, 1856. 

New York Medical Times. Edited by H. D. Bulkley, M. D. April, May, 
and June, 1856. 

The American Journal of Insanity. Edited by the Officers of the New York 
State Lunatic Asylum. April, 1856. 

Southern Medical and Surgical Journal. Edited by Drs. Dugas and Rossig- 
nol. April, May, and June, 1856. 

The American Medical Monthly. Edited by Edward H. Parker, M. D. 
April, May, and June, 1856. 

Nashville Journal of Medicine and Surgery. Edited by W. K. Bowling, 
M. D., and Paul F. Eve, M. D. April and May, 1856. 

The Peninsular Journal of Medicine and the Collateral Sciences. Edited 
by Z. Pitcher, M. D., and A. B. Palmer, M. D. April and May, 1856. 

The Virginia Medical Journal. Edited by Drs. McCaw and Otis. April and 
June, 1856. 

The Western Lancet. Edited by T. Wood, M. D. April, May, and June, 
1856. 

The American Journal of Dental Science. Edited by Chapin A. Harris, 
M. D., D. D. S„ and A. Snowden Piggot, M. D. April, 1856. 

The Medical and Surgical Reporter. Edited by S. W. Butler, M. D. April, 
May, and June, 1856. 

The Medical Counsellor. Edited bv R. Hills, M. D. April, Mav, and June. 
1856. 

The New Hampshire Journal of Medicine. Edited by Geo. H. Hubbard, 
M. D. April, May, and June, 1856. 

The Monthly Stethoscope and Medical Reporter. Edited by G. A. Wilson, 
M. D., and R. A. Lewis, M. D. April, May, and June, 1856. 

Buffalo Medical Journal. Edited by Sanford B. Hunt, M. D. April, May, 
and June, 1856. 

The New York Journal of Medicine. Edited by S. S. Purple, M. D., and 
S. Smith, M. D. May, 1856. 

The American Journal of Science and Arts. Edited by Profs. B. Silliman, 
B. Silliman, Jr., and D. Dana. May, 1856. 

The Medical Independent. Edited by Henry Goadby, M. D., E. Kane, 
M. D., and L. G. Robinson, M. D. May and June, 1856. 

American Journal of Pharmacy. Edited by William Procter, Jr. Mav, 
1856. 

Charleston Medical Journal and Review. Edited by C. Happoldt, M. D. 
May, 1856. 

The Louisville Review. Edited by S. D. Gross, M. D., and T. G. Richard- 
son, M. D. May, 1856. 

The Ohio Medical and Surgical Journal. Edited by John Dawson, M.D.. 
and R. Gundry, M. D. May, 1856. 

Memphis Medical Recorder. Edited by A. P. Merrill, M. D. May, 1856. 

Iowa Medical Journal. Edited by Drs. M. Gugin and Allen. March and 
April, 1856. 

The Southern Journal of the Medical and Physical Sciences. Edited by 
Drs. Currey, Jones, Atchison, King, and Ramsey. May, 1856. 

Quarterly Summary of the Transactions of the College of Physicians of 
Philadelphia, from November 7, 1855, to February 6, 1856, inclusive. 



CONTENTS 



OF THE 



AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

NO. LXITI. NEW SERIES. 
JULY, 1856. 



ORIGINAL COMMUNICATIONS. 



MEMOIRS AND CASES. 

ART. PAGE 

I. Physical, Chemical, and Physiological Investigations upon the Vital 
Phenomena, Structure, and Offices of the Solids and Fluids of Animals. 
By Jos. Jones, M. D., of Georgia. (An Inaugural Dissertation for the 
Degree of M. D., in the University of Pennsylvania.) - - - - 13 

II. On CEdeina Glottidis resulting from Typhus Fever. By Thomas Addis 
Emmet, M. D., late Visiting Physician to the New York State Emigrant 
Hospital, Ward's Island. 63 

III. Cases of Rupture of the "Womb, with remarks : being a Sequel to a 
Monograph upon this subject, in this Journal for January and April, 
1848. By James D. Trask, A. M., M. D., of White Plains, New York. . 81 

IV. Description of a Valve at the Termination of the Right Spermatic 
Vein in the Vena Cava, with Remarks on its Relations to Varicocele. 

By John H. Brinton, M. D. (With a plate.) - 111 

V. Case of Spinal Apoplexy. By Isaac G. Porter, M. D., of New London, 
Conn. - - - - - ... - 118 

VI. Obstetrical Memoranda. By Richard McSherry, M. D., of Baltimore. 122 

VII. On Wire Splints. By J. C. Nott, M.D., of Mobile, Ala. - - - 125 

VIII. On Liquidambar Styraciflua. By Charles W. Wright, M. D., Pro- 
fessor of Chemistry in the Kentucky School of Medicine. - 126 

IX. Inversion of the Uterus, replaced on the Third Day. By Isaac G. 
Porter, M. D., of New London, Conn. 127 



REVIEWS. 

X. Physical Exploration and Diagnosis of Diseases affecting the Respira- 
tory Organs. By Austin Flint, M. D., Professor of the Theory and Prac- 
tice of Medicine in the University of Louisville, &c. .... 129 



8 



CONTENTS. 



ART. PAGE 

XI. Statistics and Treatment of Typhus and Typhoid Fever, from Twelve 
Years' Experience gained at the Seraphim Hospital, in Stockholm 
(1840—1852). By Magnus Huss, M. D., Professor in the Medical Clinic 
at the Caroline Institute ; Member of the Royal Academy of Science at 
Stockholm ; Laureate of the Institute of France, etc., etc. Translated 
from the Swedish original by Ernst Aberg, M. D. London : Longman, 
Brown, Green and Longmans. 1855. 8vo., pp. 200. - 141 

XII. Chimie Appliquee a la Physiologie et a la Therapeutique. Par M. le 
Docteur Mialhe, Pharmacien de PEmpereur, Professeur Agrege a la 
Faculte de Medecine, &c. &c. Paris, 1856. 164 



BIBLIOGRAPHICAL NOTICES. 

XIII. Proceedings of American Medical Societies : — 

1. Proceedings of the South Carolina Medical Association, at the Extra 
Meeting in Columbia, July 5, 1854, and of the Annual Meeting in 
Charleston, Feb. 5, 1855. 8vo. pp. 104. _ 

2. Transactions of the South Carolina Medical Association, at the Extra 
Meeting in Greenwood, July 18, 1855, and at the Annual Meeting in 
Charleston, Feb. 6, 1856. 8vo. pp. 54. 

3. Transactions of the Sixth Annual Meeting of the Medical Society of 
the State of North Carolina, held at Salisbury, N. C, May, 1855. 8vo. 
pp. 40. 

4. Transactions of the State Medical Society of New York, at its Annual 
Meeting, Feb. 1856. 8vo. pp. 254. 

5. Proceedings of the Convention and of the Medical Society of Cali- 
fornia, held in Sacramento, March, 1856. 8vo. pp. 36. ... 174 

XIV. Reports of American Institutions for the Insane. 

1. Of the Maine Insane Hospital, for the years 1854 and 1855. 

2. Of the New Hampshire Asylum for the Insane, for the years 1854 

and 1855. 

3. Of the Vermont Asylum for the Insane, for the years 1854 and 1855. 

4. Of the Massachusetts Lunatic Hospital, Worcester, for the years 1854 

and 1855. 

5. Of the Boston Lunatic Asylum, for the year 1852. 

6. Of the New York City Lunatic Asylum, for the years 1854 and 1855. 

7. Of the Maryland Hospital for the Insane, for the years 1853, 1854, 

and 1855. 

8. Of the Mount Hope Institution, for the years 1854 and 1855. 

9. Of the Western Lunatic Asylum, Virginia, for the years 1854 and 

1855. 

10. Of the South Carolina Lunatic Asylum, for the years 1853 and 1855. 189 

XV. Deux Memoires sur la Physiologie de la Moelle Epiniere, lus a PAca- 
demie des Sciences, le 27 Aoftt et le 24 Septembre, 1855. Par le Doc- 
teur E. Brown-Sequard. Laureate de l'Academie des Sciences, etc. etc. 
8vo. pp. 42. Paris, 1855. 

Recherches Experimentales sur la transmission croisee des Impressions 
Sensitives dans la Moelle Epiniere. Par le Docteur E. Brown-Sequard, 
etc. etc. 8vo. pp. 19. Paris, 1855 > 

Proprietes et Fonctions de la Moelle Epiniere : Rapport sur quelques Ex- 
periences de M. Brown-Sequard. Lu a la Societe de Biologie, le 21 
Juillet, 1855. Par M. Paul Broca, Professeur Agrege k la Faculte de 
Medecine, etc. 8vo. pp. 35. Paris, 1855. 

Two Memoirs on the Physiology of the Spinal Cord, read to the Academy 
of Sciences August 27 and September 24, 1855. By E. Brown-Sequard, 
M. D. 

Experimental Researches into the Decussation which takes place in the 



CONTENTS. 



9 



ART. 



PAGE 



Transmission of Sensitive Impressions through the Spinal Cord. By E. 
Brown- Sequard, M. D. 
Properties and functions of the Spinal Cord : A Report on some Experi- 
ments of M. Brown-Sequard. Read to the Biological Society, July 21, 
1855. By M. Paul Broca. 201 

XVI. Clinical Lectures on Surgery. By M. Nelaton. From Notes taken 
by Walter F. Atlee, M. D. Philadelphia : J. B. Lippincott & Co., 1855. 
8vo. pp. 755. - 207 

XVII. Human Physiology. By Robley Dunglison, M. D., LL. D., Profes- 
sor of the Institutes of Medicine in Jefferson Medical College, Phila- 
delphia, etc.: "Vastissimi studii primas lineas circumscripsi." Haller. 
With five hundred and thirty-two illustrations. Eighth edition, revised, 
modified, and enlarged. Two volumes, 8vo. pp. 729-755. Philadelphia, 



XVIII. A Practical Treatise on the Diseases of the Testis, and of the Sper- 
matic Cord and Scrotum. With numerous wood engravings. By T. B. 
Curling, F. R. S., &c. &c. Second American, from the second revised 
and enlarged English edition. Philadelphia: Blanchard & Lea, 1856. 



XIX. Manual of Materia Medica and Therapeutics. Sixth edition, re- 
vised and enlarged. Bv Prof. Fr. Oesterlen. Published by Haupp & 
Siebeck, Tubingen, 1856. - - - 215 

XX. New Remedies ; with Formulae for their Preparation and Administra- 
tion. By Robley Dunglison, M. D., Professor of the Institutes of Medi- 
cine, etc. in the Jefferson Medical College. Seventh edition. Phila- 
delphia: Blanchard & Lea, 1856. 8vo. pp. 769. 217 

XXI. The Principles of Surgery. By James Miller, F. R. S. E., F. R. C. 
S. E., Professor of Surgery in the University of Edinburgh, &c. &c. &c. 
Fourth American, from the third and revised English edition. Illus- 
trated by two hundred engravings on wood. Philadelphia : Blanchard 

& Lea, 1856. 8vo. pp. 696. 218 

XXII. The Dissector's Manual of Practical and Surgical Anatomy. By 
Erasmus Wilson, F. R. S., author of "A System of Human Anatomy/' 
&c. Third American, from the last revised London edition. Illustrated 
with one hundred and fifty-four wood engravings. Edited by William 
Hunt, M. D., Demonstrator of Anatomy in the University of Pennsyl- 
vania. Philadelphia : Blanchard & Lea. 219 

XXIII. Atlas of Cutaneous Diseases. By J. Moore Neligan, M. D., Eclin., 

M. R. I. A. &c. &c. Philadelphia : Blanchard & Lea, 1856. 4to. PI. XVI. 220 



1856 : Blanchard and Lea. 



209 



8vo. pp. 419. 



210 



10 



CONTENTS. 



QUARTERLY SUMMARY 



OF THE 



IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 
FOREIGN INTELLIGENCE. 



Anatomy and Physiology. 



1. On the Animal Starch and Cel- 12. The Earthy Phosphates in Urine, 
luiose Question. By Yirchow. - 221 By Neubauer. - 222 



Materia Medica and Pharmacy. 

3. Quinated Cod-Liver Oil. By M. Donovan. 223 

Medical Pathology and Therapeutics, and Practical Medicine. 

4. Asphyxia, its Rationale and its and Frequently Repeated Doses 
Remedy. By Marshall Hall, i of Quinine. By Dr. Thomas B. 

M. D. 224 | Peacock. 230 

5. On Jugular Venesection in As- 8. Bronzed Skin and Disease of the 
phyxia, Anatomically and Ex- Supra-Renal Capsules. By Mr. 
perimentally Considered. By Jonathan Hutchinson. - - 23S 
Dr. Struthers. - 227 | 9. Starch as an external applica- 

6. Syncope Senilis, arising from j tion in Cases of Smallpox and 
Gastric Irritation. By Mr. John . ! other Skin Diseases of an Inflam- 
Higginhottom. - 228 \ matory Nature. By Dr. Thos. 

7. On Treatment of Fever by Large W. Belcher. - -238 



Surgical Pathology and Therapeutics, and Operative Surgery. 



10. Amputations. By Dr. Menzies. 238 

11. Analysis of Cases of Amputa- 
tion of the Limbs in the Radcliffe 
Infirmary, Oxford. By Edward 

L. Hnssey, Esq. - _ - - 242 

12. Excision of Elbow-Joint. By 
Mr. Syme. - - - 244 

13. Excision of the Knee-Joint. By 
Peter Brotherston, Esq. - - 244 

14. Tic Douloureux cured by Ex- 
cision of a Mass of Phosphate of 
Lime, adhering to the Supra- 
orbital Nerve. By Hugh Sharp, 
Esq. 245 ( 

15. Gunshot Wounds. By Dr. G. 

H. B. Maeleod. - - 246' 

10. Hemorrhage following Gun- 
shot Wounds. By G. II. B. 
Maeleod. - - - - - 248 
17. Escape of Great Vessels, by 
their Elasticity, from Balls. By 
G. H. B. Maeleod. - - - 250 



18. The Warm Bath in the Treat- 
ment of Wounds, Especially 
those made in Amputation. By 
M. Langenbeck. 

19. Surgical Uses of Glycerine. 
By M. Demarquay. - 

20. New Method of Treating Pha- 
gedena. By Mr. Cock. ■ 

21. Is it always necessary to resort 
to Amputation when a Limb is 
attacked with Sphacelus ? By 
Prof. Bardinet. 

22. Practical Deductions from a 
Clinical Record of Twenty-six 
Cases of Strangulated Femoral 
Hernia. By Mr. Birkett. ■ 

23. Mode of Reducing Strangulat- 
ed Hernia, after failure of the 
Taxis, by a Bloodless Operation. 
By M. Seutin. .... 

24. Radical Cure of Hvdrocele. 
By Mr. Lloyd. - - 



- 250 



- 255 



- 256 

257 
258 



CONTENTS. 



11 



Ophthalmology. 



25. Anemic Protrusion of Eyeball. 

By Robt, Taylor, Esq. - -258 

26. Observations on Cataract. By 
Mr. Wharton Jones. -> - - 262 



27. Traumatic Cataract and its 
Treatment by Operation. By 
Mr. J. V. Solomon. - - - 263 



Midwifery. 

28. Spontaneous Version of the 30. Placenta Prsevia. By Dr. Thos. 
Child. By Dr. Benda. - - 265 Bradford 269 

29. Complete Inversion of the i 31. On the Depth at which the Pla- 
Uterus at the Time of Labour, < centa is Implanted in the Ute- 
with remarkable Absence of the rus. By Dr. Yon Ritgen - - 279 
Ordinary Symptoms of that Ac- 32. Period of Exclusion of Pla- 
cident. By F. W. Montgomery. centa. Bv Dr. Yon Ritgen. -279 
M. D. ..... 265 



Medical Jurisprudence and Toxicology. 

33. Effects of the Humours of the I 34. Method for the Detection of 
Toad on the Animal Economy. Phosphorus in Cases of Poison- 

By M. Gavini. - - - - 279 | ing. By E. Mitscherlich. - 280 



AMERICAN INTELLIGENCE. 
Original Communications. 



Indigo Detected in the Urine. 

Charles Frick, M. D. 
Case of Monstrosity. By II. 

Marthens, M. D. 



Bv i Experimental Physiology. By Da 

- 281 vid R. Walton, M. D. 
C. 

- 281 



282 



Case of Erythema Tuberculatum et 
(Edematosum. By Dr. Silas 
Durkee. 283 

Necrosis of Inferior Maxilla from 



Domestic Summary. 

Vapour of Phosphorus. By Dr. 



James R. Wood. 
Obituary Record. 



288 
- 288 



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THE 

AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOE JULY 185 6. 



Art. I. — Physical, Chemical, and Physiological Investigations upon the 
Vital Phenomena, Structure, and Offices of the Solids and Fluids of 
Animals. By Jos. Jones, M. D., of Georgia; (An Inaugural Disserta- 
tion for the Degree of M. D., in the University of Pennsylvania.) 

Preliminary Remarks. — These investigations were carried on during two 
summer vacations, in Liberty County, Georgia, where the author had access 
to the Fishes, Reptiles, Birds, and Mammalia inhabiting the sea, salt water 
rivers, marshes, and inland forests, swamps, and rice fields. Some of the 
difficulties which attended them will be evident from the following extract 
from Dr. Holbrook's admirable work upon North American Herpetology : — 1 

" The science which treats of the form, organization, habits, and history of 
Keptiles, has been more neglected than all other branches of Zoology; for the 
study of Reptiles offers difficulties more numerous and insurmountable than 
those presented by any other class of vertebrate animals. Inhabiting, for the 
most part, deep and extensive swamps, infected with malaria, and abounding 
with diseases during the summer months, when reptiles are most numerous, 
time is wanting to observe their modes of life with any prospect of success. 
Regarded, moreover, by most persons as objects of detestation, represented as 
venomous, and possessed of the most noxious properties, few have been hardy 
enough to study their character and habits." 

Added to these difficulties which beset the way of the naturalist, the 
organic chemist and physiologist must often spend many fatiguing hours in 
fruitless attempts to secure alive the shy and wary Ophidians, Saurians, and 
Chelonians. After wading through the swamps and marshes for half a day, 
if a living subject should be secured, it must be carried home, and its blood 
and organs examined without delay. The difficulties of careful organic ana- 



1 North American Herpetology, by J. E. Holbrook, M. D., Vol. i. page 10 ; Phila- 
delphia, 1836. 

No. LXIIL— July 1856. 2 



14 Jones, Investigations on the Solids and Fluids of Animals. [July 



lysis, and physiological investigations, are greatly increased by the previous 
fatigues and exposures. We hope that those who are disposed to criticise the 
extent and character of these investigations, will remember the difficulties 
with which we had to contend. 

My investigations extended over the four great classes of vertebrate ani- 
mals, and did not embrace the invertebrate kingdom. It was necessary, also, 
to consider carefully the laws which govern the structure and development of 
invertebrate animals. The chapter upon their solids and fluids, contains a 
condensed summary of those facts and principles, mentioned by various 
modern and ancient Comparative Anatomists, which have an immediate 
bearing upon our investigations. The sections upon the structure and de- 
velopment of the circulatory and respiratory systems contain not only a 
condensed view of the important facts mentioned by the various writers, 
but also original observations made from numerous dissections, and accurate 
weights of the hearts and organs. 

I cannot enter upon these investigations without first acknowledging the 
numerous and lasting obligations which I owe to my revered teacher and 
friend, Dr. Samuel Jackson, Professor of the Institutes of Medicine in the 
University of Pennsylvania. The greatest pleasure of this truly noble and 
generous philosopher, is to inspire the minds of his students with his own 
ardent love for the truth. If these investigations possess any value, it is due 
as much to his brilliant instruction, kind advice, and generous assistance, as 
to my own exertions. I would also return my hearty thanks to Dr. Edward 
Hallowell, of this city, for numerous opportunities of examining the viscera of 
rare reptiles. 1 

1 To those who may wish to pursue the study of comparative anatomy, physiology, 
and chemistry, I would respectfully recommend the following works, which are readily 
accessible to American students. 

It would be, perhaps, useless, to give a list of the numeous articles scattered 
throughout the different Journals, as it would be of service to those only who live in 
cities, and have access to large scientific libraries, and are without doubt well ac- 
quainted with these subjects. 

Anatomy of the Invertebrata. By Siebold; translated by TV. J. Burnett, M. D. 
Boston, 1854. 

Anatomy of the Invertebrata. By Bichard Owen. London, 1855. 
Dana on Zoophytes. Philadelphia, 1846. 

General Outline of the Organization of the Animal Kingdom. By Thomas Bymer 
Jones, F. R. S. London, 1855. 

Wagner's Comparative Anatomy of the Vertebrate Animals. Translated by Alfred 
Tulk. New York, 1845. 

Outlines of Comparative Physiology. By Louis Agassiz and A. A. Gould. Boston, 
1848; republished in Bohn's Scientific Library. London, 1851. 

Carpenter's Principles of Comparative Physiology. London, 1854, and Philadel- 
phia, 1854. 

Miiller on the Glands. Translated by S. Solly. London, 1839. 
Griffith's Cuvier's Animal Kingdom, 16 vols. London, 1832. 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 



15 



Vital Force. — In studying the progressive development of the blood, and 
the organs and apparatuses of the invertebrate and vertebrate kingdoms, we 
are met with difficulties at every step of our progress. Errors of observation, 
arising from imperfections of our senses and instruments, and errors arising 
from mental preconceptions and prejudices, obscure the light of truth. An- 
other source of difficulty and error, arises from the complex nature of all the 
phenomena, and the limited extent of our knowledge. Oftentimes, those who 
have had the best opportunities for observing the secret operations of nature, 
have devoted their undivided time and attention simply to the description of 
the habits, exterior forms, and colours, of plants and animals. These ob- 
servations are all useful, and aid profound researches by affording classifica- 
tions, and determining the geographical distribution of living animals. They 
may give us a general insight into a few of the obvious phenomena of life, 
but they can never unfold the laws which regulate the development of the 
animal and vegetable kingdoms. A knowledge of these can only be ac- 

North American Herpetology. By J. E. Holbrook, M. B., Professor of Anatomy 
in Medical College of the State of South Carolina. 5 vols. Philadelphia, 1842. 

Human Anatomy. By J. Quain, M. B., and W. Sharpey, M. B. Philad., 1849. 

Kolliker's Microscopical Anatomy. Translated under the direction of the Syden- 
ham Society. Philadelphia, 1854. 

Miiller's Physiology. Translated by W. Baly, M. B. London, 1840. 

The Chemistry of Animal and Vegetable Physiology. By G. J. Mulder. Trans- 
lated by J. T. W. Johnson. London, 1849. 

Simon's Animal Chemistry, with reference to the Physiology and Pathology of Man. 
Translated by G. E. Bay. Philadelphia, 1846. 

Traite de Chimie, Anatomique et Physiologique, &c. Par C. Robin and F. Ver- 
deil. Paris, 1853. 

Bernard and Robin on the Blood. Translated by Atlee. Philadelphia, 1854. 
Memoirs on Respiration. By Lazarus Spallanzani. London, 1805. 
Bigestion. By Lazarus Spallanzani. London, 1800. 

Lectures on the Physical Phenomena of Living Beings. By C. Matteucci. Trans- 
lated by J. Pereira, M. B. Philadelphia, 1848. 

Manual of Physiology. By W. S. Kirkes, M. B., and J. Paget. Philad., 1849. 

Carpenter's Principles of Human Physiology. Philadelphia, 1856. 

Carpenter's Principles of General Physiology, including Organic Chemistry and 
Histology. Philadelphia, 1854. 

Longet— Treatise on Physiology. Translated by F. G. Smith, M. B. Philad., 1856. 

Xehmann's Physiological Chemistry. Translated by G. E. Bay, M. B., and edited 
by Prof. R, E. Rogers. Philadelphia, 1855. 

Lehmann's Manual of Chemical Physiology. Translated by J. C. Morris, with an 
Essay on Vital Force, by Br. Samuel Jackson. Philadelphia, 1856. 

Manuals of Blood and Urine. By Griffith, Reese, and Markwick. Philad., 1848. 

Golding Bird on Urinary Beposits. Philadelphia, 1854. 

Bowman's Practical Chemistry. Philadelphia, 1849. 

A Practical Handbook of Medical Chemistry. By J. E. Bowman. Philad., 1856. 
Kidneys and Urine. By Berzelius. Philadelphia, 1843. 
Prout on Urinary Biseases. Philadelphia, 1826. 



16 Jones, Investigations on the Solids and Fluids of Animals. [July 

quired by studying carefully all the chemical, physical, and vital phenomena, 
and by examining the development, structure, and function of all the organs, 
apparatuses, and systems, commencing with the simplest, and ascending to 
the most complex organism. 

Although this science may be said to be but in its infancy, still we have 
facts sufficient to show, that there is a grand uniformity in the plan of the 
development of all the component parts of the animal kingdom. By this we 
do not mean, that the organs and apparatuses of every higher animal pass 
through in their development, successively, all the forms of those placed 
below in the scale of creation. Neither is it possible to arrange all animals 
in one straight line, commencing with the simple cell animalcule, and ending 
with the complicated organism of man. While the vital force which presides 
over the development of all organized beings has certain common properties, 
and fashions after certain common methods, inorganic and organic materials, 
still each species, genus, order, and class of animals has its own peculiar pro- 
perties of the vital force, which acts according to fixed and immutable laws, 
established by the Creator, and which can be altered by him alone. We 
have a demonstration of this in the fact, that different species, genera, and 
classes of animals, have retained their identity from generation to generation, 
from the foundation of the world. All the facts of geology prove that the 
laws which regulate the development of animals, are fixed and immutable. 
Varieties may arise, but one species has never been transmuted into another 
by either physical or chemical influences. If this were not so, where would 
the foundation of the science of Natural History, in its most extended sense, 
be laid ? The creation of a force, by whose modifications the physical and 
vital constitution of every living being on earth, in air or water, is precisely 
adapted to fulfil certain definite ends, necessarily presupposes a Creator, who 
constructed, comprehended, and controlled all the physical, chemical, and 
vital laws which regulate the universe. Whether the human mind will ever 
be able to grasp in one view all the modifications, phenomena, and laws of 
life, remains for future researches to show. The comprehension of the phe- 
nomena of life in the higher animals, necessarily requires not only a perfect 
knowledge of all the chemical and physical laws which govern all matter, but 
also of that subtle force, which, like the mind, has escaped the view of all 
observers. 

Before proceeding to the physical, chemical, anatomical, and physiological 
investigations of the blood and organs of different animals, it is necessary 
that we should give sufficient proof of the existence of a vital force, distinct 
from the nervous, chemical, and physical forces. 

Certain physiologists have denied the existence of a vital force. Others, 
admitting its existence, affirm that it is identical with nervous force; and 
nervous force they prove to be identical with electricity. According' to this 
doctrine, the vital and nervous forces are purely physical phenomena. 

Those who deny the existence of any peculiar vital or organizing force, 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 17 

must admit that suitable matter, placed under the requisite conditions for the 
production of living beings, will be capable of generating animals by simple 
physical and chemical means. Careful experiments have been performed by 
Dr. Joseph Leidy 1 and others, 2 by placing the elements of organic structures 
under all the requisite conditions for the commencement and maintenance of 
life action; and never have they discovered a single instance where a living 
being, animal or vegetable, even of the simplest structure, has been produced 
by these physical agents alone. Place a germ under these conditions of heat, 
moisture, and a supply of oxygen, and immediately it begins to develop an 
organized being. It is a universal law of nature, that every living being 
has descended from a germ, which was derived from a parent, and the first 
parent was the creation of the Deity. Through these microscopical points of 
matter have been transmitted from generation to generation, unchanged, all 
the peculiarities of each species, genus, and class. What a concentration of 
forces ! Wherein does a germ differ from any other form of organized mat- 
ter ? The ultimate chemical elements are the same with a piece of muscle, 
and yet, when placed under precisely the same conditions, the one putrefies, 
whilst the other develops a living being. Have we here no proof of a special 
force ? 

Again : take two germs — they are alike in appearance, and ultimate chemi- 
cal constitution, and require precisely the same conditions for their develop- 
ment, and yet one will form a cold-blooded animal, whose circulation is 
sluggish, nervous system imperfectly developed, the chemical and physical 
changes in its blood slow, and all the phenomena of life correspondingly fee- 
ble; whilst from the other will be developed a bird, whose circulation is 
rapid, nervous system highly developed, the changes in the elements of its 
tissues and blood incessant, and its temperature correspondingly high. 
Whence this difference ? Does not this show that each species in the animal 
economy is endowed with its own special vital force ? That this difference is 
due to this and this alone, is demonstrated by a fundamental law, that like 
causes produce like effects. If there be no vital force, organic matter placed 
in certain circumstances, and acted upon by definite chemical and physical 
laws, must always yield the same results. Organic matter placed in the 
situation of these germs, is invariably decomposed into simpler forms, and 
finally resolved into its ultimate chemical elements. Under the same circum- 
stances, and acted upon by the same agents, the action of the germ is directly 
opposite, being that of construction, building up, instead of decomposition 
and destruction. 

The chemical and physical forces always act in a direction directly oppo- 

1 Flora and Fauna within Living Animals, by Joseph Leidy. Smithsonian Contri- 
butions to Knowledge, vol. v. art. 2, 1853, p. 11. 

2 By F. Schulze, Berlin. Edinburgh New Philos. Journal, vol. xxiii. p. 165, 
1837. 



18 Jones, Investigations on the Solids and Fluids of Animals. [July 

site to that of the vital force. The former are constant and invariable in 
their intensity and direction under like circumstances, whilst the latter varies 
in direction and intensity. When, therefore, they act simultaneously upon 
matter, the living being the resultant of these actions will be imperfectly or 
highly developed, according as the vital force is feeble or powerful. 

The great distinction, then, between animals of different species and 
classes, depends originally upon the vital force, which presides over the de- 
velopment of every molecule of organized matter, and guides and controls all 
its physical and chemical actions. According to the perfection of this organic 
or vital force will be the development of the organic system, and centraliza- 
tion of the forces. 

The lowest plants and animals consist of simple cells without any special 
organs or apparatuses. In these simple forms, the germ force is distributed 
equally through ever} 7 molecule of matter. Trembley 1 performed a series of 
careful experiments upon reproduction by artificial sections in the Hydra. 
One hydra was cut in half, and each became a perfect animal; another was 
divided into three portions, and a head produced a tail, the middle portion a 
head and a tail, and the tail a head. New tentacles replaced those cut off, 
and a longitudinal cut in the body was soon united. Different individuals 
were engrafted upon each other, as is frequently done in trees. The heads 
and tails of two polyps were mutually changed, and they united perfectly, 
or what is still more curious, the tail of one may be substituted for the head 
of another ; and if the tail of one be placed in the head of another, they unite 
heads and tails. A single hydra was divided into forty parts, and as many 
distinct animals were formed. 

No such results have ever been obtained with the higher animals. Accord- 
ing as the nervous system is developed, the index of the vital force, will be 
the centralization and perfection of all the forces. Hence, for the formation 
of the germ in the higher animals, we have special apparatuses. If the origi- 
nal germ cells of any organ or highly developed tissue be destroyed, they can 
never be replaced. The wound in the skin or muscles is never united by true 
skin or muscular fibres, but by the simplest form of tissue, the fibrous, which 
is analogous to that which composes the whole mass of the lower animals. 

The next question which demands our attention is, whether or not the 
vital and nervous forces are distinct ? 

In nature there exist two great kingdoms. They both arise from one 
common origin — the organic cell. In the twilight of animal existence, the 
simple cell-animalcule can hardly be distinguished from the sporules of vege- 
tables. The simplest forms of animals have been often confounded with 

1 A. Trembley, on Freshwater Polyps, 1 vol. 4to. Ley den, 1744; and Phil. Trans., 
vol. viii. of Abridgment, 1742. See also Baker's Natural History of the' Polype, 
8vo. London, 1743. Rare and Remarkable Animals of Scotland, by J. G. Dalyell, 
vol. i. p. 28. Prof. F. Forbes' British Star-Fishes, p. 199. 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 19 

plants, by the best observers, and the character of many of these individuals 
is still involved in obscurity. Every day the distinctions between the two 
kingdoms are disappearing. Most of the important organic products which 
were thought to distinguish the vegetable from the animal, have been found 
in both kingdoms. Cellulose has been discovered in the brain, 1 spleen, 3 and 
liver; and sugar 3 is the constant product of the action of the liver from both 
nitrogenized and non-nitrogenized organic matters. Motion no longer sepa- 
rates the animal from the vegetable world. This property of matter appears 
to be most incessantly exercised in the minutest organisms. The motion of 
the minute eilise of vegetables is known to every one. The contraction of the 
leaves of the sensitive plant is a familiar example. The only distinction be- 
tween the lowest orders of the two kingdoms, the Protozoa and Algae, is that 
the former possess, to a certain extent, voluntary motion. 

In the vegetable kingdom, from the simple cell to the most complex and highly 
developed tree, we discover not the first rudiment of a nervous apparatus, or a 
cell-generating nervous force. Here we have the evidences of the existence of a 
force requiring the same conditions for its existence and operations — heat, 
moisture, oxygen, and a germ — which are necessary for the production of an 
animal organism entirely independent of any nervous system. Does not this 
fact demonstrate conclusively, that nervous force is entirely distinct from the 
vital ? 

The conclusion is sustained also by facts drawn from the animal king- 
dom. In the lowest forms of animals, not even the rudiment of a nerve-cell 
can be discovered, and yet these beings possess the attributes of vitality, 
and even nervous force. They carry on all the acts of digestion, secretion, 
nutrition, and growth; possess voluntary motions, and are capable of receiv- 
ing impressions from without. Dana, 4 in his work upon Zoophytes, states 
that, upon pressing the tip of a branch of a large Alcyonium, in the Fejees, 
there was an immediate contraction of . every polyp throughout the whole 
zoophyte, although extending to a breadth of four feet, and composed of 
many thousands of individuals. The existence of any special nervous system 
in these animals is denied by the best comparative anatomists of the present 
day, and yet they possess the sensation of higher animals, manifested in the 

1 By Rudolph Virchow (Virchow's "Arch," B. vi. h. 1, p. 135). Also, by G. 
Busk, F.R.S. Journal of Microscopical Science, No. vi. p. 101. 

2 By R. Virchow, Comptes Rendus, No. 23, December 2, 1853. Monthly Journal 
of Medical Science, January, 1854. 

3 By M. Claude Bernard, " Nouvelle Fonction du Foie," Paris, 1853, chap. 11. See 
also, Secretion of Sugar by the Liver, and its modification by disease, by M. Vernois. 
Monthly Journal Med. Sci., Nov. 1853, from Archiv. Gen., 1853. Dr. Gilb, on the 
Relation that Fat bears to the Presence of Sugar in the Livers of the Mammalia and 
Birds. Paper read before the Physiological Section of the Medical Society of London 
(April 10, 1854). See Abstract in American Journal Med. Sci., July, 1854, p. 211. 

4 Structure and classification of Zoophytes, by J. D. Dana, p. 14. Philadelphia, 
1846. 



20 Jones, Investigations on the Solids and Fluids of Animals. [July 

selection of food, and the reception of impressions from light and foreign 
bodies. 

Again — has any one ever discovered nerves or nerve-cells in a germ? 
The primary nerve-cells are not formed until after the commencement of 
change, and the formation of the germ material into cells. The apparatus 
for the generation of the nervous force is the product of the vital force. 

It is a remarkable fact, and one which gives confirmation to these views, that 
the cells — the active agents in the formation of all the secretions, and separation 
of all the excretions — are always separated from the bloodvessels and nerves, 
and in no case do they come in contact. The cell of the most complicated 
structure differs, as far as its acts are concerned, in no essential degree from 
that of a vegetable or simple cell-animalcule. Every cell in the whole animal 
and vegetable economy is capable of carrying on the offices of nutrition, 
secretion, and growth, whether they be supplied with nervous force, or de- 
prived of it. Every individual animal or vegetable, simple or complex, is 
composed of organic cells ; therefore, the conclusion is inevitable, that deve- 
lopment, nutrition, secretion, and excretion, are directed by the vital force, 
which is incorporated with, and presides over, every molecule of organized 
matter, directing and controlling all its physical and chemical laws, so that 
amidst innumerable and unceasing changes, the individuality of every organ, 
apparatus, and animal is preserved. According to the development of this 
force will be the perfection of the organism which it constructs. 

I. Solids and Fluids of Invertebrate Animals. — Before commencing the 
consideration of the blood and organs of cold-blooded animals, it will aid us, 
in the study of the progressive development of the fluids and solids of organ- 
ized beings, to review briefly the fluids, organs, and apparatuses of the inver- 
tebrate kingdom. The classification is that adopted by Siebold. 1 

This science is by no means perfect, and every system of classification must 
be more or less imperfect. It is impossible to represent upon paper the rela- 
tion existing between different classes, and their mode of connection with each 
other. The lowest members of a class which stands high in the system of 
classification are often as low, or lower, in the development of the nervous 
system and all the organs, than classes which stand far below. Notwithstand- 
ing that the lowest members of each class resemble each other in the simplicity 
of their structure and the absence of special organs, still the study of the 
invertebrate kingdom as a unit reveals general lines or systems of development 
branching up from the simple cell-animalcule to the highly organized Cephalo- 
pod. Therefore, in studying accurately the progressive development of the 
fluids and solids of these animals, we must commence with the lowest members 
of each class, and proceed to the highest. In the present article, however, we 

1 Comparative Anatomy of the Invertebrata, by Siebold. Translated from the 
German by W. J. Burnett, M. D. Boston, 1854. 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 21 

can do no more than present those anatomical and physiological details and 
principles which have an immediate bearing upon our researches upon the 
vertebrata. 

In the lowest forms of the Protozoa, which are simple cells provided with 
vibratile cilias, and resembling closely the sporules of vegetables, we find 
neither organs nor a circulatory system. Careful microscopical researches 
have failed to detect a nervous system; and yet these animals appear, by their 
voluntary motions, to possess sensation. If a nervous system exists, it must 
be reduced to its molecular condition. 

In the highest members of this group we discover the first rudiments of a 
circulatory system, and an attempt at the interchange of the fluids from dif- 
ferent parts of the body. 

All the Stomatoda have contractile pulsatory cavities situated in the denser 
and outer layers of the parenchyma of the body, varying in form, number, 
and arrangement in different species. During their expansion, these cavities 
become filled with a clear, transparent, colourless liquid, which disappears en- 
tirely during the contraction. These movements succeed each other, ofttimes, 
at regular intervals. In some cases, however, regularity between the diastole 
and systole cannot be determined, owing to the number of these pulsatory 
cavities. No bloodvessels communicate with these cavities, and no special 
walls have been discovered surrounding them; and the fluid which they con- 
tain, although analogous to blood, contains no corpuscles. By these simple 
means, corresponding to the structure of these animals, the fluids of the body 
are prevented from stagnation ; and a free interchange of the nutritive ele- 
ments promoted. 

In the Polypi — inarticulate fleshy bodies, having a simple visceral cavity, 
with a single opening at the centre above, without intestines, without glands 
separate from the walls of the visceral cavity, with no distinction of sex, and 
an imperfectly developed nervous system in the highest and none whatever in 
the lowest — the circulatory system is rudimentary, and the fluid which it dis- 
tributes nothing but the digested matters of the visceral cavity. This circu- 
latory fluid contains a few spherical corpuscles, apparently albuminous, and a 
few oil-globules. According to Dr. T. Williams, 1 a few of these corpuscles 
appear to be nucleated, others appear to contain secondary cells, and others, 
again, are charged with minute granules. The fluid is incapable of coagu- 
lation, and contains albumen in very small amount. In the tubular axis of 
colonial Polyps, which communicates with the visceral cavities of all the indi- 
viduals composing the colony, something analogous to the circulation of the 
blood was discovered, by Cavolini, 2 in 1785. His observations have been con- 

1 Memoir on the Blood-proper, and Chylaqueous Fluid of Invertebrate Animals, by 
Dr. T. Williams. Philos. Transact., 1852. Brit, and For. Med.-Chir. Review, vol. 
xii. p. 484. 

2 " Memorie per Servire alia Storia de' Polipi Marini." Naples, 1785. 



22 Jones, Investigations on the Solids and Fluids of Animals. [July 



firmed by Dana, Lister, and other observers. From the article of J. J. Lister, 1 
published in the Philosophical Transactions, we quote the following interesting 
observations upon the vibratory motion of the contents of the tubular axis of 
colonial Polyps : — 

"The current flowed in one channel, alternately backwards and forwards, 
through the main stem and lateral branches of a plume, and through the root 
as far as the opacity admitted of its being traced ; sometimes it was seen to 
continue into the cells. The stream was throughout in one direction at one 
time; it might be compared to the running of sand in an hour-glass, and was 
sometimes so rapid in midtide that the particles were hardly distinguishable ; 
but it became much slower when near the change. Sometimes it returned 
almost without a pause ; but at other times it was quiet for a while, or the par- 
ticles took a confused whirling motion for a few seconds ; the current afterwards 
appearing to set the stronger for the suspension. Five ebbs and five flows occu- 
pied fifteen minutes and a half; the same average time being spent in the ebb 
as in the flow." 

Professor Dana, in his work upon Zoophytes, 2 states that, in his observations 
upon one of the Sertularidae, the vibrating contents of the tubular axis had a 
greenish tint, and appeared to be derived in part from the digested food of the 
stomach. This circulation of the products of digestion, without any elabo- 
ration by special organs, reminds us strongly of the formation of the fluid 
contents of cells in the vegetable kingdom. 

The nervous system of the highest species of the Acalephse is more deve- 
loped than that of the Polyps, and the blood and circulatory system appear 
to be correspondingly highly developed. The nervous system, however, is in 
too imperfect a condition to call for the production of any special organs. 
In these transparent gelatinous animals a circulatory system has been described 
by Will. 3 Their entire bodies are traversed by canals, which receive water 
from the stomach, or directly from without, and, being lined by cilise, a con- 
stant renewal of the water is effected. These aquiferous canals, which should 
be regarded as a respiratory system, are accompanied and surrounded by ves- 
sels having exceedingly thin walls. These sanguiferous vessels are without 
ciliated epithelium, and have neither longitudinal nor circular fibres. In some 
species they contain a greenish fluid, with spheroidal and slightly elongated 
red corpuscles with large nuclei. 4 In others the corpuscles are brown; and in 
others, again, they are of a greenish colour. There is no regular circulation, 
the blood being shifted hither and thither by the irregular contractions of the - 
body. According to Agassiz, the circulatory system opens directly by large 
tubes into the alimentary canal. The fluid, therefore, which they circulate is 
the direct product of digestion. The blood of the Acalephse should be re- 
garded as of a higher type than that of the Polyps, because its corpuscles are 

1 Philosophical Transactions, 1834, p. 369. 

2 P. 21. 3 Horse tergest, p. 34. 

4 These observations of Will are not sustained by those of Dana and Agassiz. 
See Contributions to the Nat. Hist, of the Acalephss, by Agassiz. Boston, 1850, p. 
260. 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 23 

larger, contain more granules and oil-globules, and their cell-membranes are 
more distinct. 

Much confusion and imperfection exists in the descriptions of the vascular 
sanguineous system of the Echinodermata, arising from the fact that the re- 
spiratory system has been often confounded with the circulatory. All the 
researches, however, show that the higher members of this order have a dis- 
tinct circulatory system separated from the alimentary canal, composed of 
arterial and venous trunks, between which, in some species, there is an organ 
analogous to a heart. In some species, as the Holothurinse, there is no distinct 
heart, but the vascular system is well defined. It consists of a ring around 
the oesophagus, which sends off a trunk, which may be compared to the aorta. 
This ramifies upon the intestines and genital organs. By a reunion of these 
ramifications a second trunk is formed, analogous to the vena cava. This 
divides into two vessels, which ramify upon the branchiae. From the branchiae 
arise two veins, which return to the aorta. The Echinodermata is the only 
class amongst the Radiata in which a proper circulation of the nutritive fluid 
takes place, and this is attended with a corresponding development of the 
nervous and muscular systems, and the organs of secretion. It is in this class 
that we first find the liver, in its rudimentary state, however, consisting of 
simple caeca opening into the digestive cavity. It is remarkable that the cir- 
culatory fluid does not exhibit corresponding marks of higher elaboration. It 
appears to differ from the contents of the digestive cavity only in a greater 
degree of concentration. This fact, connected with another asserted by Dr. 
Williams, that the movement of the circulatory fluid is mainly carried on by 
ciliary motion, renders it probable that more careful and extended researches 
will discover some communication between the digestive cavity and the circu- 
latory system. According to Dr. T. Williams, the corpuscles resemble 
spherules, composed of hard and very minute granules of coagulated albumen, 
without any detectable nucleus or cell-wall, or oily particles, and are readily 
broken up into their individual molecules. In the Spiunculida, the highest 
order of this class, the corpuscles are more highly developed, being flat and 
irregularly oblong, having small, bright, highly refractive nuclei. 

As each class in the invertebrate kingdom passes through very much the 
same stages of development, and, moreover, as the object of these observa- 
tions is to develop principles which will guide us in our future researches, and 
not to enter into a minute description of all the anatomical details of the 
structure of the solids and fluids of these animals, which may be readily ob- 
tained elsewhere, we will pass directly to the consideration of the comparative 
anatomy and physiology of the Mollusca. 

In the lowest families of the class Acephala, the nervous system consists of 
a simple ganglionic mass, the intestinal canal is a simple cavity, and the liver 
composed of small single or ramified glandular follicles, thickly set together, 
and covering a large part of the alimentary canal. The circulatory system 
and fluids are correspondingly feebly developed. In the lowest species the 



24 Jones, Investigations on the Solids and Fluids of Animals. [July 

heart is simple, whilst in the higher it is composed of both auricles and ven- 
tricles. In Salpa the heart is simple, and forces the blood alternately back- 
wards and forwards in different directions. In the Lamellibranchia the nervous 
system is distinct, and composed of a central ganglionic and a peripheric sys- 
tem. The senses and the muscular and organic systems are correspondingly 
highly developed. The liver is voluminous, distinct from the intestine, and 
consists of brown lobular masses. An excretory organ also makes its appear- 
ance, formerly called the gland of Bojanus. The circulatory system corre- 
sponds in perfection with the advance in the structure of the solids of the 
body. The heart is divided into three chambers, and surrounded with a large 
pericardium. Two lateral, triangular, thick-walled auricles receive the blood 
from the branchiae, and send it into a single muscular ventricle. By the 
contraction of this ventricle, the blood is sent into the body by a posterior and 
anterior aorta; its return into the two auricles being prevented by valves. 
Here we have, for the first time, the type of heart which exists in vertebrate 
animals. The blood is colourless, and contains many pale granular globules, 
often indistinctly nucleated. According to Siebold, the blood-corpuscles of 
the Naiades have an irregular form, and run together when placed upon a 
watch-glass. This may be due to the coagulation of the fibrin. When treated 
with acetic acid, they separate, become clear and almost imperceptible, and a 
hitherto invisible nucleus is brought into view. In this reaction they re- 
semble closely the blood-corpuscles of the vertebrata. 

In the lowest members of the class Cephalophora a heart and circulatory sys- 
tem are absent, or exist in a rudimentary condition; the biliary organs consist of 
numerous small follicles surrounding the intestines; no traces of kidneys or sali- 
vary glands are present, and the nervous system is correspondingly rudimentary 
in its structure and arrangement. In the highest order of this class, the nerv- 
ous system is more perfect, and the organs of vision and hearing present. The 
digestive apparatus is complicated, and in those individuals nourished by solid 
food we find highly developed salivary glands. The liver is isolated, and often 
divided into lobes of a brownish-green colour. The biliary canals arising from 
the hepatic lobules form two or more secretory ducts, which empty the bile 
into the stomach or intestines. The heart is always present, consisting of a 
thin-walled auricle, generally single and rarely double, and a single muscular 
ventricle. The heart is surrounded by a distinct pericardium. The circulation 
is analogous to that of higher animals. The arterial blood passes from the 
respiratory organs into the auricle, then into the ventricle, and is forced, 
through a very short aorta, over the body. The heart is generally situated in 
the bottom of the pulmonary cavity, or at the base of the branchiae, its po- 
sition depending generally upon that of the respiratory system. The two 
chambers of the heart are separated by a valve. The development of the 
respiratory system corresponds with the perfection of the nervous system and 
organs. In the lowest orders it is absent. The blood is colourless, except in 
Planorbis, in which it is red. It is often opalescent, and always poor 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 25 

in corpuscles. The corpuscles are colourless, smooth cells, with a granular, 
indistinct nucleus, which is rendered very distinct by the action of acetic acid. 
According to Leydig, the blood of Paludina contains two forms of corpuscles, 
one round, which becomes granular nucleated cells after the action of acetic 
acid, and the other provided at one side with processes which disappear under 
the action of acetic acid. The blood of the Cephalophora generally contains 
a small quantity of fibrin, which, when coagulated, forms a web uniting the 
globules in masses and rows. 

We pass now to the last division of the Mollusca, the Cephalopoda, which 
may be considered as belonging to the former class, only more highly organ- 
ized. They have the rudiments of an internal skeleton, and a well-developed 
muscular system. The nervous system is more highly developed than that of 
any class which we have thus far studied, having a central portion resembling 
the brain of the vertebrata, in the extraordinary increase of its ganglionic 
substance, and in being contained in a cartilaginous cranium. All the organs, 
except the spleen, which are found in the vertebrata, exist in this class. They 
have organs of sense corresponding in perfection with the development of the 
nervous system; digestive apparatus complicated in structure; salivary glands 
highly developed; a pancreas present in some species; the liver present in all, 
and consists of a compact glandular mass, with distinct excretory ducts; kidneys 
also present. The circulatory system does not appear to be more highly de- 
veloped than that of the other mollusca, the principal characteristics of which 
have been already described. The blood shows an elaboration corresponding 
to the perfection of the organs and apparatuses of the Cephalopoda. It coagu- 
lates spontaneously upon standing, and the number of corpuscles is greatly 
increased. They inclose numerous granules, thus resembling the colourless 
corpuscles of the vertebrata. The majority of the blood-corpuscles are colour- 
less; some few, scattered here and there, have a violet hue. 

II. Fluids and Solids of Vertebrate Animals. — 1. Circulatory and Respi- 
ratory Systems. A minute investigation of all the varieties of the circulatory 
system of vertebrate animals would occupy more than a lifetime, and com- 
plete descriptions would fill large volumes. In this paper, we can do nothing 
more than give those general outlines of the development of the circulatory 
and respiratory systems, which are absolutely necessary to enable us properly 
to understand the physical, chemical, and physiological phenomena of the 
different classes of animals. Commencing with the lowest of all vertebrate 
animals, the connecting link with the invertebrata, we will ascend rapidly to 
the highly organized Mammalia. 

The circulatory system of the Amphioxus, or Branchiostoma (Lancelet), 
resembles closely that of some of the Annelida, as the Eunice, in its division 
and the distribution of numerous pulsatile dilatations upon the different vas- 
cular trunks. Miiller enumerates as belonging to the circulatory system of 
this singular animal, the following parts : — 



26 Jones, Investigations on the Solids and Fluids of Animals. [July 

1. The Arterial Heart, a thick vessel of uniform calibre, situated in the 
median line, immediately beneath the branchial chamber, between the arches 
forming the framework of that cavity. Posteriorly, it is continuous with the 
heart of the vena cava. From its sides are given off the bulbs of the 
branchial arteries, varying in number with that of the branchial arches, from 
twenty-five to fifty on each side. These bulbs are situated at the commence- 
ment of the branchial arteries, and by their contractions propel the blood 
into the capillary network surrounding the branchial arches. 

2. The Aortic Heart, whinh discharges the function of a systemic heart. 

3. The Heart of the Vena Portse, a long contractile vessel which runs 
along the under surface of the intestine as far as the hepatic organ. 

4. The Heart of the Vena Cava, which is opposite to the heart of the 
vena portae, and lies superiorly to the hepatic cseca. The contraction of 
these hearts succeed each other at regular intervals. Each in turn becomes 
filled with the colourless blood, whilst the others successively contract. The 
blood does not appear to be more highly elaborated than that of the Cephalo- 
pods, and contains none of the coloured corpuscles of higher vertebrate ani- 
mals. 

The respiratory system is formed upon an equally degraded type. The 
branchial apparatus is placed in the same cavity in which are lodged the 
liver, kidneys, generative apparatus, and greater portion of the intestinal 
tube. A similar arrangement is seen in the respiratory system of many of 
the invertebrata. The nervous and organic systems are correspondingly sim- 
ple in their structure. The canal which incloses the spinal column, presents 
anteriorly no cranial expansion, but the spinal chord extends from one ex- 
tremity to the other. This fact, in connection with others of a similar cha- 
racter in the invertebrate kingdom, demonstrates that the brain is but a 
developed portion of the spinal column. The liver is reduced to its rudi- 
mentary condition, a greenish glandular layer, lining a portion of the intes- 
tines. The imperfect development of the fluids and solids of this animal 
would lead us to place it below the Cephalopods. 

It is remarkable that the spleen is also absent in this animal. The ap- 
pearance of the spleen in vertebrate animals is accompanied by an improve- 
ment of all their organs, apparatuses, and nutritive fluids. This little organ 
is the herald, rather than the cause of these great changes. Its presence 
indicates a higher development of organization. 

Traces of an arrangement of the circulatory apparatus similar to that of 
the Amphioxus, are found in some other fishes, especially in the cartilaginous 
group. It is remarkable that in some of these cartilaginous fishes, as the 
Stingray (Trygon Sabinoi), the pancreas, kidneys, and generative apparatus, 
are more highly developed than in the osseous fishes, having more perfect 
nervous and osseous systems. The young of the Stingray is developed in a 
uterus. The appearance of this organ, and the attachment of the foetus 
resembles closely the arrangement of these parts in the highest mammalia. 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 27 



These facts confirm what has been before asserted, that each higher animal 
does not pass through successively all the stages in the development of those 
placed below. Whilst the general plan of the development of the solids and 
fluids is similar in all animals, still each species, genera, and class has its own 
peculiar laws of development, which are immutable. The principal, or only 
heart, in many Fishes, has but one auricle and one ventricle. It is tra- 
versed by venous blood alone and corresponds with the right heart of the 
higher vertebrata. The heart is lodged within a pericardium, to the inner 
surface of which it is frequently attached, as in many Amphibia. In the 
lowest orders of Fishes, as the Plagiostomi, the pericardium communicates by 
openings with the peritoneum, and is bathed by the water introduced through 
the apertures in the peritoneum, situated near the anus. In most Fishes, 
especially those beloDging to the osseous division, the cavity in which the 
heart is lodged, is separated from the peritoneum by a kind of tendinous 
diaphragm, and also by a capacious sinus which collects the venous blood 
from all parts of the body preparatory to its admission into the auricle of the 
heart. The auricle is more capacious and has much thinner walls than the 
ventricle. Between the two cavities we find generally two, and rarely three 
muscular valves. From the anterior part of the ventricle arises the contrac- 
tile trunk of, the branchial arteries, which consist of very powerful annular 
muscular fibres, and is situated within the pericardium. This strongly deve- 
loped portion of bloodvessel is called the bulbus arteriosus, and by its con- 
tractions aids materially in the circulation of the blood. It is separated from 
the ventricle by strong valves, and is so muscular and capacious, that it should 
be considered as forming a second ventricular chamber. The venous blood 
from all parts of the body is collected in the auricle, and by its contractions 
is transmitted to .the ventricle. The contraction of the ventricle forces the 
blood through the bulbus arteriosus into the branchial arteries, generally four 
in number, which pass in a groove in the convex side of each branchial arch, 
and ramify upon the branchial leaflets. The capillary network thus formed, 
terminates at its other extremity in the branchial veins, which run along in 
the same groove in the branchial arches behind the arteries in an opposite 
direction. The branchial veins run up to the base of the skull and com- 
mencement of the vertebral column, and there form an extensive circle of 
arterial vessels, from which arises posteriorly the aorta, the contractions of 
which performs the oflice of the left ventricle in higher animals, and propels 
the slow moving blood in its course through the arterial system. This great 
systemic artery divides and subdivides and distributes the arterial blood to 
all the organs and tissues of the body. The arterial blood, after having tra- 
versed the capillaries, becomes venous, and after being elaborated and puri- 
fied by the action of the liver and kidney is returned by the systemic veins, 
into a large dilatation (sinus venosus), which enters the posterior part of the 
auricle of the heart by a large orifice, guarded by two membranous valves. 
In Fishes, as in many Amphibia, we find a double portal system, one for the 



28 Jones, Investigations on the Solids and Fluids of Animals. [July 

liver, and the other for the kidneys. The venous blood from the stomach, 
intestinal canal, spleen, pancreas, and sometimes the generative organs, enter 
the liver in different parts by several branches, and rarely unite into a com- 
mon portal vein. The kidneys receive blood from the tail, and partly also 
from the sexual organs and swimming bladder. The arrangement of the 
portal systems varies in different species and genera. The venous blood, 
after it has been elaborated by the liver and purified from certain effete com- 
pounds, empties into the great venous sinus, and from thence is conveyed to 
the heart. Several peculiarities of the circulatory apparatus which connect 
the Fishes with Reptiles and the foetus of higher vertebrata deserve an especial 
notice. 

The heart of the Chick, about the 65th hour of incubation, and that of 
the foetus of the dog, about the 21st day of its development, resembles, in 
many respects, that of Fishes and the larvse of the Batrachians. It then 
consists of two cavities and a bulbus arteriosus. In warm-blooded ani- 
mals, this bulbus arteriosus, between the third and fifth days in the chick, 
and longer in the Mammalia, gives off a succession of arches which encom- 
pass the pharynx, and are true analogues of the branchial arches of Fishes. 
These are successively obliterated, and the bulbus arteriosus finally subdi- 
vides into two branches, one communicating with the left, and the other with 
the right ventricle. The former subsequently becomes the aorta, and the 
latter the pulmonary artery. In some Fishes, which present distinct reptilian 
characteristics, there is a slight indication of this division of the bulbus 
arteriosus. Another peculiarity exists in the circulation of Fishes which dis- 
tinguishes it from that of the invertebrata, and foreshadows more important 
modifications in the higher classes. Two or more small arteries pass off from 
the branchial arches, and convey pure aerated blood to the head and brain. 
A similar arrangement exists in the Alligator and the embryo of higher ver- 
tebrata. In the Alligator and other reptiles, only a moiety of the blood 
passes through the respiratory organs, the arterial and venous blood being 
mixed directly in the heart, or by communications between the two systems. 
The partially vitiated blood of the heart would be unfit for the supply of so 
important an organ as the brain, and consequently special arteries supply it 
with purified blood, directly from the lungs. As the organism is developed, 
the nervous system is correspondingly developed, and greater provisions made 
for its maintenance and preservation. The importance of the preservation 
of the nervous system is farther seen in the development of the bony case in 
which it is contained, which is ossified just in proportion to tHe perfection of 
the organs and apparatuses. In all the invertebrate animals except the 
highest Cephalopods, we find no special internal framework. In the lowest 
Fishes it is cartilaginous. In the foetus of mammalia it is in the earlier 
stages entirely cartilaginous. 

In the Garfish (Lepisodeus 6sseus) } we find a still higher development of 
the circulatory and respiratory systems. In this remarkable fish ; the only 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 29 

representative of the great Sauroid family of the earlier periods of the earth's 
history, we find a capacious lung resembling, in all respects, the structure of 
the respiratory organs in the Amphiuma Means, and other reptiles. The 
blood is sent to the lungs oy prolongations of the branchial arteries. The ca- 
pillary network formed by the ramification of these vessels carrying arterial 
blood, terminates in vessels which transmit the aerated blood directly into 
the aorta. This singular fish has both a branchial and pulmonary respira- 
tion. I have often watched them, when lying near the surface of the water, 
expel the vitiated air in a rapid succession of small bubbles through the 
nostrils, and then quickly with a splash of the tail and flirt of the body, 
thrust their long bill into the air, and draw in a fresh supply. 

Having rapidly traced the development of the circulatory apparatus from 
the Amphioxus or Branchiostoma to the most highly organized Fishes, we pass 
next to the class of Eeptiles. 

The circulatory apparatus of Eeptiles presents many varieties dependent 
upon the peculiar organization and metamorphoses of the different orders. 
We can only notice those peculiarities of structure and development which 
have an important bearing upon our investigations. 

The family Phanerobranchoidea, the members of which have permanent 
gills, ranks next to the class of Fishes in their modes of life, and the general 
development of the respiratory and circulatory systems and organs. 

In the Lepidosiren, a creature so exactly intermediate between Fishes and 
Eeptiles, that it is difficult to determine to which class it belongs, the heart 
consists of a single auricle, a ventricle, and a bulbus arteriosus; the ven- 
ous blood from all parts of the body is conveyed by the vena cava directly 
into the auricle ; the pulmonary vein bringing the aerated blood from the 
lung, enters the ventricle by a distinct orifice, guarded by a cartilaginous 
valvular tubercle. The continuation of the pulmonary vein prevents the 
admixture of the venous and arterial blood until they have reached the 
cavity of the ventricle. The bulbus arteriosus connected with the ventricle 
gives off on each side six vessels corresponding to the number of the branchial 
arches. Four of these arches on each side support gills, and are supplied by 
a corresponding number of arteries. The two remaining arteries on each 
side are continued around to the dorsal region, and give off the pulmonary 
arteries, and then unite to form the aorta. Each contraction of the ventricle 
of the heart, assisted by that of the bulbus arteriosus, drives the mixed blood, 
derived from the venre cavse and pulmonary veins, first to the gills, secondly 
to the aorta, and thirdly to the lungs. By this arrangement, whether the 
animal be placed in water or in air, respiration is carried on vicariously, either 
by the branchial or pulmonary apparatus. The only difference between the 
circulation of the Lepidosiren and the Garfish (Lepiso'steus o'sseus) is, that 
in the former, the pulmonary vein empties into the ventricle of the heart, 
whilst in the latter it empties into the aorta. 

In the Siren and Menobranchus we have a still higher development of the 
No. LXIIL— July 1856. 3 



30 Jones, Investigations on the Solids and Fluids of Animals. [July 

circulatory apparatus by the dilatation of the pulmonary vein into a left auri- 
cle. The heart in these animals consists of two auricles, separated by a thin 
septum, a ventricle, and a bulbus arteriosus. Within the ventricle of the 
Siren there is even found a rudimentary septum. The vessels carrying ve- 
nous blood, unite and form the large superior and inferior venae cavse, which 
dilate, as in Fishes, into a contractile venous reservoir (sinus venosus). The 
venous blood from all parts of the body collected into this sinus venosus is 
driven into the right auricle of the heart. The pulmonary veins, bringing 
aerated blood from the lungs, empty into the left auricle. The contraction of 
the two auricles sends the blood into the common ventricle, in which we have 
a mixture of the venous blood from all parts of the body and the aerated 
blood from the lungs. The contraction of the ventricle forces the blood 
through the bulbus arteriosus into the branchial arteries, which terminate in 
a capillary network upon the branchial arches. This capillary network of the 
gills ends in three branchial veins, which unite in a common trunk, and 
anastomosing with that of the branchial veins of the opposite side, form the 
descending aorta, which distributes the oxygenated blood throughout the sys- 
tem. By comparing the circulation of these animals with that of Fishes, we 
see at once that the only difference is the existence of a lung and a left auricle 
devoted to the reception of the aerated blood. Remove the lung and left 
auricle, and you have remaining the simple heart of fishes with its bulbus 
arteriosus, circulating only arterial blood. 

In the Menopoma and Amphiiima, which have branchial arches without 
any capillary network forming gills, a farther advance is made towards that 
form of the circulatory apparatus which exists in the Chelonia and Sauria. 
The bulbus arteriosus divides into branchial arteries; but as in the adult 
animals there are no branchiae, these vessels wind around the side of the neck, 
and again unite into a trunk on each side. The union of these two trunks 
forms the aorta. From the lowest branchial arch a pulmonary artery is 
given off, which ramifies over the surface of the lung. In the earlier con- 
ditions of the development of the Salamanders and Batrachians, the circula- 
tory system presents successively those arrangements which we have described 
as permanent in the Phanerobranchoidea. 

In the larvae of the Batrachia, the heart consists of a single auricle and 
ventricle, a bulbus arteriosus, and a sinus venosus, and the circulatory appa- 
ratus resembles in all respects that of Fishes. The left auricle is formed as the 
lungs develop. In the earlier period of the development of the Tadpole, the 
pulmonary artery is a minute branch, derived from the aortic system, and 
corresponds with the rudimentary condition of the lungs. The greater por- 
tion of the blood goes to the branchiae, whilst only a very small part passes 
through the lungs. Minute vessels at this period unite the branchial arteries 
with the branchial veins, which increase in importance during the subsequent 
stages of the metamorphosis. As the branchiae with their arteries and veins 
diminish with the progressive development of the lungs and pulmonary 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 31 

arteries, the anastomosing vessels are correspondingly enlarged. When the 
lungs are fully developed, and the Batrachian prepared for the habitation of 
the land, the branchiae entirely disappear, and the circulation is carried on 
as in the Aniphiurua and Menopoma, through the anastomosing branches. 
These branchial arches exist permanently in all Reptiles, and are also found 
as a transitory condition in the development of the circulatory apparatus of 
warm-blooded animals. 

In the higher orders of cold-blooded animals, the Ophidia, Sauria, and 
Chelonia, the circulatory apparatus is more perfectly developed, but still a 
mixture of venous and arterial blood always takes place in the ventricle. The 
heart consists of three cavities, two capacious auricles and a strong muscular 
ventricle. The auricular cavities are separated from the ventricle by valves. 
The general shape of the heart varies with the different orders. Thus, it is 
elongated in the Ophidia and Sauria, and short and broad in the Chelonia. 
The ventricle in these higher orders is generally divided by an imperfect sep- 
tum, which in the heart of the Alligator is very strong and almost complete. 
J ust at the outlet of the ventricles, however, we find a communication established 
between the two, and thus the vitiated and purified blood is mixed together, 
and the similarity with the heart of the rest of the Reptiles and the foetus of 
birds and mammalia is preserved. The venous blood from all parts of the 
body is returned to the right auricle of the heart through the vense cavse, the 
terminations of which are guarded by strong valves. The left auricle is 
appropriated exclusively to the lungs, from which it receives the aerated 
blood through the pulmonary veins. From the single ventricle two sets of 
vessels are sent off, the pulmonary and the aortic. The pulmonary artery 
divides into two branches, one for each lung. The aorta, immediately after 
its origin, divides into two trunks, which, winding backwards, join and form 
a large vessel, the branches of which distribute the blood to all parts of the 
system. The contraction of the right auricle forces the venous blood into 
the ventricle, whilst the contraction of the left auricle transmits the aerated 
blood from the lungs into the same common cavity. The contraction of the 
ventricle distributes a portion of the mixed blood into the lungs through the 
pulmonary artery, and the remainder to all parts of the body, through the 
aorta and its branches. From this arrangement it is evident that not only 
is partially aerated venous blood diffused throughout the system, but also 
only a moiety of the whole amount of blood is sent to the lungs and exposed 
to the action of the atmosphere at each contraction of the ventricle of the 
heart. 

These peculiarities in the structure of the circulatory apparatus in Reptiles 
should be attentively studied; for they will aid us materially in the inter- 
pretation of some of the most complex phenomena of life. As the circula- 
tory apparatus is developed, the influence and importance of the nervous 
system is increased, and corresponding arrangements established for its perfect 
preservation. The brain of many reptiles, especially that of the most highly 



32 Jones, Investigations on the Solids and Fluids of Animals. [July 

organized, as the Sauria, is supplied by small arteries given off from the left 
arch of the aorta, which is connected with the left ventricular cavity, and 
contains pure blood. The same condition exists up to the termination of the 
embryo state of the higher vertebrata, including the human species. The 
portal system of Reptiles corresponds with that of Fishes, in the circumstance 
that both the kidneys and liver are supplied with venous blood. The minute 
and extended description of the hepatic, portal, and renal circulations will be 
postponed until the anatomical and physiological description of these organs. 

From the consideration of the heart of the Alligator we pass very naturally 
to that of warm-blooded animals. The circulatory apparatus differs in no 
essential respect in the two great classes of warm-blooded animals — Birds and 
Mammalia. In these higher animals we have a double heart, and two dis- 
tinct and complete circulations of the blood. Each portion of blood which 
has passed through the capillaries of the system, and become vitiated, is 
aerated in the lungs before its distribution over the body. This is one of the 
most important of all distinctions between warm and cold blooded animals. 
The right heart is devoted to the circulation of venous blood, and the left 
heart to the circulation of oxygenated or arterial blood. The auricle and 
ventricle of one heart has no communication with the auricle and ventricle of 
the other, except through the bloodvessels and capillaries. The vessels of 
each heart are distinct, and perform distinct offices. It is unnecessary to enter 
into a minute description of all the anatomical details, as these are familiar to 
every one, or may be readily reviewed in all the works on human anatomy. 
The right auricle receives the venous blood from all parts of the system, and 
transmits it to the right ventricle. The contraction of the right ventricle 
distributes the venous blood to the lungs. The aerated blood is conveyed 
from the lungs to the left auricle, and from thence to the left ventricle, and 
the contractions of this distributes it throughout all parts of the system. In 
Birds, the portal circulation resembles to a certain extent that of reptiles. 
The portal trunk receives its blood, not only from the veins of the digestive 
apparatus, but also by branches from those of the pelvis and posterior 
extremities, and still communicates with the renal circulation. The portal 
circulation in Mammalia is limited to the liver, the kidneys being supplied 
with arterial blood alone. 

The circulatory apparatus of warm-blooded vertebrata, during its develop- 
ment, passes through very nearly all the stages, which exist as permanent 
conditions in the lower animals. Thus the bloodvessel system is formed and 
a motion of the blood commenced, before the formation of a heart. The 
heart, in its earlier conditions, is a simple tube. At a later stage of its 
development, like that of Fishes, it consists of only two cavities and a bulbus 
arteriosus. Branchial arches in the earlier periods are given off, analogous 
in all respects to those of the Menopoma and Amphiuma, and Reptiles gene- 
rally. Finally, the heart assumes the form of that of the most highly 
organized reptiles, as the Alligator, and this condition continues up to within 
a short period of the completion of the embryo. 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 33 



We will next consider the relative size of the heart, and the rapidity of its 
action in different animals. I obtained the following results by carefully 
weighing the entire body of an animal, and then carefully ascertaining the 
weight of its heart upon a delicate balance capable of turning to the T ^oth 
part of a grain. By dividing the former by the latter, the weight of the 
heart in comparison to that of the body is ascertained, and may be compared 
with others. 

Comparative Weights of the Hearts of Fishes. 

(' Number of times hea- 
Tier than its heart. 



Weight of female Stingray (Trygon Sabina) . . . 1012 

" foetus of Stingray ( Trygon Sabina) . . . 1070 

" Hammerhead Shark (Zygozna malleus) . . 1156 

" Hammerhead Shark (Zygosna malleus) . . 899 

" female Garfish (Lepisdsteus dsseus) . . . 965 

Comparative Weights of the Hearts of Reptiles. 

Weight of Bullfrog (Rdna pipiens) ..... 576 

" female Black Viper (Heterodon niger) . . . 496 

" male Black-snake ( Cdluber constrictor) . . . 425 

" Coachwhip-snake (Psdmmophis flagellifdrmis) . 354 

" male Corn-snake ( Cdluber guttdtus) . . . 400 

" male Rattlesnake ( Crdtalus durissus) . . . 441 

" Alligator Cooter (Chelonura serpentina) . . 405 

" Loggerhead Turtle ( Cheldnia cardtta) . . . 480 

" Chicken Terrapin (Emys reticulata) . . . 420 

" Yellow-belly Terrapin [Emys serrdta) . . . 592 

" Yellow-belly Terrapin [Emys serrdta) . . . 577 

" Yellow-belly Terrapin [Emys serrdta) . . . 543 

" male Gopher ( Testudo polyphemus) . . . 455 

" male Gopher (Testudo polyphemus) . . . 470 

" female Alligator (Alligator Mississippiensis) . 398 

Comparative Weights of the Hearts of Birds. 

Weight of Wild Turkey (Meledgris gallopavo) . . . 279 

" Wild Turkey (Meledgris gallopavo) . . . 275 

" Hooting Owl (Syrnium nebuldsum) . . . 220 

" Turkey-Buzzard ( Cathdrtes atrdtus) . . . 113 

" Wood Ibis ( Tantalus loculator) 108 

" Wood Ibis ( Tantalus loculator) .... 100 

Comparative Weights of the Hearts of Mammalia. 

Weight of common Sheep 256 

" Gray Squirrel (Sciurus Carolinensis) . . . 261 

" Opossum (Didelphis Virginidnus) . . . 280 

" Raccoon (Prdcyon Utor) 164 

" Raccoon (Prdcyon Utor) 140 

" young Raccoon (Prdcyon Utor) .... 142 

" common Cat 275 

Pointer Dog . . . . . ... 128 



34 Jones, Investigations on the Solids and Fluids of Animals. [July 



By comparing these tables, we see that the heart is smallest in Fishes, and 
largest in Birds. As the organs and apparatuses of the animal economy are 
developed and perfected, the necessity for a vigorous circulation of the nutri- 
tive materials becomes more urgent. As the temperature, intelligence, and 
activity of animals, with their corresponding physical and chemical metamor- 
phoses of the elements of organic structure, increase, there is a corresponding 
necessity for a rapid supply of those materials by which the wastes may be 
repaired, and from which the various secretions may be elaborated and sepa- 
rated. The importance of the facts demonstrated by these tables will be 
evident when we come to treat of animal temperature, and compare the phe- 
nomena of cold-blooded animals with those of the warm-blooded. 

We will next consider the rapidity of the circulation in different animals. 
The action of the heart may be taken as a general index of this. "We are 
not aware that any special researches have as yet been made upon the rapidity 
of the heart's action in the different classes of the invertebrate animals. All 
comparative anatomists, however, concur in the statement that it is generally 
much slower than that of the vertebrata. The circulation of the blood in the 
tubular axis of colonial polyps is completed in about two or three minutes. 
The motion of the blood in all the invertebrata which are without a central 
organ of circulation is correspondingly sluggish. 

In the Amphioxus, whose circulatory apparatus has been previously de- 
scribed, the contractions of the several distinct hearts succeed each other at 
regular intervals, in such a manner that each in turn becomes filled whilst 
the others contract. Each heart contracts with such violence that it empties 
itself entirely, and remains for some little time undistinguishable. By this 
arrangement each portion of blood passes the entire round of the circulation 
in the time which elapses between the consecutive contractions of the separate 
hearts. The space of time occupied in the complete circulation of a given 
portion of the blood of the Amphioxus is stated to be about one minute. 

As the fluids and solids of FisJies become more highly elaborated and deve- 
loped, the action of the heart and circulation of the blood becomes more rapid 
and vigorous. . The same remark applies generally to the remaining vertebrate 
animals. These principles are illustrated by the following table, which has 
been drawn up from the researches of Dumas, Prevost, Miiller, and Simon : — 

Number of beats in a 



minute. 

Amphioxus 1 

Carp .' 20 

Fishes generally . . . . . . 20 to 24 

Green toad 77 

Frogs generally about 60 

Pigeon >. •. V. • . . . V - • " 136 

Common hen . . . . . . . . 140 

Duck • . . . . • : • ! r . . no 

Ptaven *. . . . 110 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 



85 



Number cf beats in a 



minute. 

Heroic 200 

Birds generally . . 100 to 200 

Ox 38 

iUfge* • %xm0i •«• wMfij mftr jjjij i ni:ii.iii.i'ri;i tVlffi" 
^eag .... ., v ■ . v^frj^ffftf/* 'eHV-" -W^VfrA • 75. 

Goat 84 

Hare 120 

Guinea-pig . . 140 

Dog 90 to 95 

Ape (Simia Calitriclie) ' . 90 

Human embryo 150 

just after birth 130 to 140 

Human being during the first year ..... 115 to 130 

" during the second year .... 100 to 115 

" " during the third year . . . 90 to 100 

" " about the seventh year . . . 85 to 90 

" " about the fourteenth year . . . 80 to 85 

" " in the middle period of life . . 70 to 75 

" " in old age . 50 to 65 

Mammalia generally 38 to 140 



This table shows us that the rapidity of the circulation depends upon the 
structure, habits, age, and development of animals. If the vital forces are 
of a low grade, either from original conformation or the depressing influences 
of old age, the circulation is correspondingly sluggish and, feeble. 

We will next briefly consider the development and structure of the respira- 
tory system in the different orders of animals. One of the essential conditions 
of the life of all organized beings, whether vegetable or animal, is a supply of 
oxygen. The modes in which oxygen is brought in contact with the fluids and 
solids of organized structures vary with the development and peculiar modes 
of life of the different classes of animals. In the lowest classes of the inver- 
tebrata, in which the digestive matters pass directly from the stomach into the 
different structures of the body, and become integral parts of the animal, we 
find no special circulatory system, and respiration is carried on by the whole 
surface of the body which is bathed by the water. In animals still more 
highly developed we find canals, carrying water into all parts of the system. 
In many individuals bloodvessels accompany these canals, and ramify around 
their walls. An incessant motion of the water through this aquiferous respira- 
tory system is maintained by cilite lining their interior. These canals open 
upon the exterior of the body, and into the visceral cavity. In many animals 
of this class the digestive cavity, which is bathed continually by fresh portions 
of water, performs the function of respiration. The "water vascular" system 
of the lower articulata finds its homologue in the tracheal system of air-breathing 
Myriapods and Insects. In the higher orders of the invertebrata, the respira- 



36 Jones, Investigations on the Solids and Fluids of Animals. [July 

tory system is confined to a definite portion of the exterior or internal mem- 
brane, which is developed within a small space into a great extent of surface, 
so as to render the contact with the air or water as extensive as possible, with- 
out any loss of room or power. According as the fluids are elaborated, and 
the solids correspondingly developed, the respiratory system becomes more con- 
densed and perfected. The branchial apparatus of the cephalopoda is similar 
in structure and function to that of fishes. 

Our time will not permit us to enter upon the minute details of the respira- 
tory apparatus of the different classes of the invertebrata, and we pass imme- 
diately to the consideration of the respiratory system of Fishes and the higher 
vertebrata. In the Amphioxus, the pulmonary apparatus corresponds with the 
degraded type of the cerebro-spinal system and all the organs, and, like that 
of many invertebrate animals, is lodged in the same cavity with the liver, 
generative apparatus, kidneys, and the greater portion of the alimentary canal. 

In the Cyclostome Fishes the branchial apparatus presents a remarkable vari- 
ation, being composed of six or seven pairs of gills on each side, not attached 
to the cartilaginous arches, but developed as folds from the lining membrane 
of as many distinct sacculi. In the invertebrate animals, and the Amphioxus 
amongst the vertebrata, the circulation of the water through the branchiae is 
maintained principally by ciliary action. 

In Fishes, however, of higher organization, whose blood is more highly 
elaborated, and circulates with greater rapidity, mere filamentous tufts hanging 
to the side of the neck will not suffice for the aeration of the blood. It is 
necessary that large streams of water should be constantly and forcibly pro- 
pelled through the branchial apparatus, in order that the blood should be ex- 
posed as much as possible to the action of the air scantily contained in the 
water. This is accomplished by the connection of the gills with the cavity of 
the mouth, the muscles of which send rapid currents of water through the 
branchial passages. The structure and position of the heart also are such that 
it propels all the venous blood through the branchiae before its distribution to 
the body generally. 

At first sight, the circulation and respiration of Fishes appear to be more per- 
fect than that of Reptiles; this, however, is not the case. By a reference to the 
table of the comparative weights of the heart in different animals, it will be seen 
that the heart of Fishes is about T oVo^h; whilst that of Reptiles is about 5 J ¥ th 
of the weight of the entire body. The heart of reptiles is relatively more than 
twice as large as that of fishes. The table of the comparative, rapidity of the 
heart's action in different animals shows that the circulation of Fishes is much 
slower than that of reptiles. The aeration of the blood also is much slower and 
less perfect in Fishes, from the fact that the amount of air contained in the water 
is infinitely less than that of the atmosphere. The respiratory apparatus in 
Fishes consists of cartilaginous or bony arches suspended from the hyoidean 
arch. To the convex margin of each of these branchial arches is attached a 
double row of pointed, lanceolate, vascular lamellae or leaflets, which project 



1856.] Jones ; Investigations on the Solids and Fluids of Animals. 37 

from the sides of the arch like the teeth' of a comb. Each leaflet is provided 
with a thin fibro-cartilaginous plate, which keeps it stiff and straight. The 
extent of the surface is increased by numerous transverse ridges. 

The branchial artery runs in a groove situated upon the convexity of the 
branchial arch, and sends off branches to every one of the lamellae or leaflets, 
which divide into a minute capillary network, covering both surfaces of the 
branchial fringe. This capillary network terminates in veins which empty 
into a venous canal, running along the internal margin of each lamella, and 
these last unite to form the branchial vein situated in the same groove, but 
running in an opposite direction with that of the branchial artery. By these 
arrangements, the extent of surface covered by minute capillaries, exposed to 
the action of the oxygen of the air contained in the water is very great. In 
descriptions of this character, we should bear in mind the fact that, when 
the terms veins and arteries are applied to the bloodvessels of the respiratory 
organs of animals, the character of the blood does not correspond with the 
name and office of the vessel. The branchial arteries convey venous blood 
to be exposed to the action of the air in the water, and the branchial veins 
carry aerated, or arterial blood from the respiratory organs. 

The objection may be urged against the assertion that the blood of Fishes re- 
ceives its oxygen from the air of the water, that they die in a short time when 
placed in the atmosphere which contains a far more abundant supply of oxygen. 
This, however, is readily explained when we consider the mechanism of their 
respiration and the necessity for the moisture and division of their branchial 
fringes. The mouth is first filled with water, its muscles contracting expel 
the fluid through the apertures on either side of the pharynx into the gill- 
cavity, and, at the same time, the branchial arches are lifted and separated 
from each other so that the gill-fringes hang freely. After the oxygen of the 
air has been exhausted from this portion of water, it is expelled by muscular 
pressure through the external openings, its return into the pharynx being 
prevented by valves. When a fish is exposed to the atmosphere, the fila- 
ments of the gills being no longer moistened, separated, and, supported by 
the water, become glued together, and expose but a comparatively small sur- 
face to the action of the atmosphere. Their surfaces also become dry, and 
the circulation of the blood in the minute capillaries is diminished if not com- 
pletely arrested, and as a necessary consequence, the exosmose of the carbonic 
acid and the endosmose of the oxygen is retarded. Those fishes which have 
the external opening very small, so that the gill-cavity may be kept distended 
with fluid, are capable of living for a much greater length of time out of the 
water. 

In the Labyrinthibranchii, the anterior branchial arches give origin to a 
curious lamellated apparatus similar to that of the Land-Crab, which retains 
water for a considerable length of time. The gills by this arrangement 
being kept moist, they can exist for a length of time in the atmosphere, and 
are said to perform long migrations over the land in search of food. 



38 Jones, Investigations on the Solids and Fluids of Animals. [July 

In several remarkable fish having strongly marked reptilian characters, as 
the G-arfish (Lepisosteus osseus) and the common Mudfish (Amia cdha~) of 
our southern swamps and rice fields, we find both gills and a pulmonary 
organ. The lung of these fishes has been considered by many physiologists 
and anatomists as analogous to the swimming bladder of other fishes. This 
organ is absent in some individuals, and its presence or absence in those 
which possess it, appears to make no material difference; in others it commu- 
nicates externally, whilst in others again it is completely closed, and in all its 
offices are wholly unknown. It is, therefore, impossible with our present 
knowledge to decide whether or not the air-bladder of fishes should be con- 
sidered as a rudimentary lung. 

The lung of the Garfish (Lepisosteus osseus) is a capacious fibrous sac, 
which opens by a short trachea high up in the throat and, extending nearly 
the whole length of the abdominal cavity, terminates within a short distance 
of the anus. It lies between the posterior surface of the liver and the ante- 
rior surface of the kidneys. When removed from the abdominal cavity and 
fully inflated, its diameter is nearly equal to two-thirds of that of the fish. 
Its structure resembles that of the Amphiuma Means and other doubtful rep- 
tiles. The lungs of Serpents and Terrapins are also formed upon the same 
general plan, only more highly developed. The bloodvessels ramify over the 
walls of this sac, the internal surface of which is increased by the development 
of numerous sacculi. This increased development of the respiratory system 
is attended by corresponding improvements in the structure and functions of 
the solids. The gar is a destructive and active pirate, and consequently 
needs great muscular power to outstrip and capture the swift inhabitants of 
the watery element. It is a very difficult matter to hold a recently captured 
gar, two or three feet in length, even with both hands. The contortions and 
contractions and flirts of its body are so great and sudden, that it will often 
extricate itself from a powerful grasp. When removed from the water, like 
the mudfish [Amia cdlva), it will live for a much greater length of time than 
fishes which have no pulmonary organ. 

The manner in which the lung of the Lepisosteus osseus is supplied with 
blood has been already described. Not only in this respect, but also in the 
general form and appearance of the viscera, this fish bears a strong resem- 
blance to reptiles. 

The Menobranchus Maculatus of our northern lakes, and the Phanero- 
branchoidea generally have both gills and pulmonary organs, The relative 
action of these two systems varies with the comparative development of the 
organs. The branchial apparatus of these animals resembles that of young 
Fishes during their development, and is not so perfect as that of the higher 
orders of fish. As the fluids and solids of the body are elaborated and per- 
fected, the pulmonary apparatus is correspondingly developed, and the bran- 
chial apparatus becomes more and more imperfect, until it disappears. 

These progressive changes may be studied either in the permanent states of 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 39 

the respiratory system of the Doubtful Reptiles, or in the transitory conditions 
in the development of the larvse of the Batrachia. 

In the Congo snake of our southern swamps and rice fields, and the Hellbender 
(Menopoma Alleghaniensis), we find branchial arches without any development 
of the gills. The lungs of the Congo snake (Amphiuma means'), communicate 
with the exterior through a short trachea, which opens by a slit in the pharynx 
just opposite to the base of the cranium. The trachea passes down between the 
divisions of the bulbus arteriosus, and a short distance below the position of the 
heart divides into two short branches which open into the lungs. The lungs 
are long slender sacs, having the general structure of these organs in the Batra- 
chia, Reptilia, and Chelonia. Their internal surface is increased by sacculi 
developed in their walls, upon which ramify numerous bloodvessels. The 
diameter of the lungs, even in their inflated condition, is very small, being 
about one-half of an inch, whilst their length is very great, in full-grown 
individuals being about eighteen inches. Notwithstanding the absence - of 
gills, the lungs are far smaller than the pulmonary organ of the garfish [Lepi- 
sdsteus dsseus), which has also a large and well developed branchial apparatus. 
This may be due in part to the fact that its naked skin, as in frogs and naked 
animals generally, whether vertebrate or invertebrate, performs the office of a 
lung. The chief cause, however, of these discrepancies in the development 
of the respiratory organs of these two animals is found in their habits and 
vital endowments. The Gar is active and powerful, whilst the Amphiuma is 
sluggish and degraded in habits and appearance. This is one of numerous 
instances which might be adduced to show that the consumption of oxygen and 
the corresponding wastes of the tissues correspond exactly with the development, 
habits, and temperature of animals. 

The lungs of the several orders of Reptiles are formed upon one type, being 
capacious sacs, whose walls are divided into sacculi and supplied with blood- 
vessels, according to the perfection of the organ and apparatuses, and the 
habits of the animal. From the internal surface membranous septa project 
inwards, partially dividing the interior of the organ into numerous polygonal 
cells, which are themselves subdivided into smaller compartments. The 
bloodvessels are distributed over the internal walls of the lungs and over the 
sides of the pulmonary cells. In Serpents, only one lung is developed, and 
the pulmonary. cells are most numerous in the superior portion, whilst the 
inferior part of the long cylindrical lung is a mere membranous sac with few 
or no bloodvessels ramifying upon its walls. We find the greatest number of 
the polygonal cells, and the greatest distribution of the bloodvessels in the 
pulmonary organs of the higher Chelonia and Sauria, thus foreshadowing the 
condition of the lungs in Birds and Mammalia. In these orders, the lungs 
are filled more or less by a coarse and fine network, or areolar tissue, forming 
angular or rounded meshes which rest partly upon the walls of the lungs, 
and inclose lesser meshes, or air-cells. The bloodvessels ramify over the 
meshes, as well as over the walls of the lungs. The sacculi thus formed 



40 Jones, Investigations on the Solids and Fluids of Animals. [July 

communicate with each other, and can all be inflated from any one point. 
In Amphibia and Batrachia the lungs are filled by an action that resembles 
swallowing. 

In some Chelonia we have observed a muscle which is attached to the back 
and passes over the surface of the lungs. This fan-like muscle is especially 
developed in the Emys serrata. The expansion and contraction of this mus- 
cle aids materially in the introduction and expulsion of the air. In Serpents 
and Sauria respiration is assisted by the ribs and abdominal muscles. 

The size of the lungs differs in the different orders, according to their struc- 
ture and habits. Amongst the Chelonia we find the most capacious lungs in 
the G-opher (Testudo polyphemus). These animals burrow deeply in the ground, 
and need large lungs to keep a supply of air. In aquatic serpents which 
remain under the water for a great length of time, the lungs are capable of 
holding a greater quantity than those of land serpents. 

We will next briefly consider the structure of the lungs in the warm- 
blooded animals. 

In Mammalia and Birds the blood is abundant, and the circulation rapid, 
and the wastes and metamorphoses of the tissues correspondingly great, and 
hence the lungs are composed of an infinitude of minute cells, containing air, 
and surrounded by a capillary network. The respiratory system of Birds is 
more highly developed than that of Reptiles, but not so concentrated as that 
of the Mammalia. In this class the lungs are no longer closed bags, like 
those of Reptiles, but are spongy masses of great vascularity, communicating 
with numerous air-sacs, and the cavities of the bones. The main trunks of 
the bronchial tubes pass through the lungs, and open into the cavity of the 
thorax. The whole thoracico-abdominal cavity is divided by bands of serous 
membrane into numerous cells, communicating with each other, and the cavi- 
ties of the hollow and spongy bones. Such is the freedom of communication 
between the air-cells, cavities of the bones, and the lungs, that if the trachea 
be tied, the animal will continue to respire, and support life, by an opening 
in the humerus or femur. In many birds, especially those of powerful 
flight, the air is admitted into the interspaces between the muscles, and be- 
tween the skin and muscular system. By this arrangement, which reminds 
us of the tracheal system of insects, the air penetrates almost every part of 
their bodies, bathes all their viscera, and fills the cavities of the hollow and 
spongy bones. It follows as a necessary consequence, that the actions be- 
tween the oxygen of the atmosphere and the organic elements of their bodies, 
are rapid and incessant, and the temperature correspondingly high. 

The minute structure of the lungs of Birds resembles, in many respects, 
that of Reptiles; the cells, however, are infinitely more numerous and minute, 
and the surface exposed to the action of the atmosphere correspondingly more 
extensive. The entire mass of each lung is divided into innumerable lobules 
or lunglets, the walls of which are formed by a cartilaginous network derived 
from the bronchial tubes, and by the ramifications of the capillary vessels. 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 



41 



Prom this arrangement it is evident that the bloodvessels are suspended in 
the air, and exposed to its influence on every side. These cells, or saceuli, 
are never terminal cells as in the Mammalia, but open parietal cells, com- 
municating freely with each other through the meshes of the capillary and 
cartilaginous network. The mechanism of respiration is more complete in 
this class than in Reptiles, but not so perfect as that of the Mammalia. From 
the elastic character of the cartilaginous and bony framework surrounding the 
thoracico-abdominal cavity, the natural condition of the lungs is that of in- 
flation. The air is expelled by the action of those muscles which bring the 
sternum nearer to the vertebral column. When these muscles cease to act, 
the extended sternum attached to the elastic thorax, springs outward, and the 
air rushes into the lungs to fill the vacuum thus formed. 

In the Mammalia, the abdominal cavity is completely separated from the 
thoracic cavity by the diaphragm, the great muscle of respiration. The lungs 
are closed bags, situated in the cavity of the thorax, and are surrounded by a 
serous membrane, which, after lining the ribs and intercostal muscles, and 
thoracic surface of the diaphragm, is reflected on the lungs from the point 
occupied by the pulmonic vessels. They are composed of innumerable cells 
communicating with the terminal branches of the bronchial tubes, around 
which ramify a delicate and closely woven network of bloodvessels. Col- 
lectively, these cells present an immense surface over which the blood circu- 
lates, and is exposed to the action of the atmosphere. It has been calculated 
that the number of these air-cells grouped round the termination of each 
bronchial tube, is about 18,000; and that the total number in the human 
lungs is not less than 600,000,000. 

Not only are the lungs more highly developed, but the mechanism of 
respiration is more perfect in the Mammalia than in all other animals. 

The inspiration and expiration of the atmospheric air are effected by the 
alternate movements of the diaphragm and the walls of the thoracic cavity. 

A close relation exists between the number of the respirations and the 
rapidity of the circulation of the blood. This will be seen in the following 
table, drawn up from the researches of Dumas, Prevost, and Simon :— 



Animals Number of beats of the Number of respirations 

heart in a minute. in a minute. 

Horse . . . . . . 56 . . . .16 

Hare . - ; ... . 120 . . v . .36 

Goat . . -. . . . 84 . . . .24 

Cat . . . . . . 100 . . . .24 

Dog . . . ... . 90 . . . .28 

Guinea-pig 140 . . .36 

Ape {Simia callitriche) . 90 . . .30 
'.Man ... t fl>ft^.ffi.. if ^8pt ftlTl| ^ ; 18 

Heron . . . . . . 200 . . . .22 

Raven . . . . . . 110 . . . .21 

Ducks . . . ... 110 . . . .21 

Common hen .... 140 . . . .30 

Pigeon 136 . . . .34 



42 Jones, Investigations, on the Solids and Fluids of Animals. [July 



This table shows that, as a general rule, the activity of the respiratory 
function corresponds with the rapidity of the circulation. Having studied 
the respiratory and circulatory systems, it would at first sight appear proper 
to consider the physiology of respiration. This function, however, being 
modified by the habits, food, vital, chemical, and physical constitution of 
animals, and the peculiar operations of their organs and apparatuses, its con- 
sideration will be delayed until we have studied the chemical and physical 
properties of the blood and all the organs in a normal state, and under the 
influence of starvation and thirst, and a change of diet. 

The following important facts and principles have been derived from this 
review of the invertebrate and vertebrate kingdoms : — 

1. The development of the circulatory system, and elaboration of the blood, 
is always accompanied by corresponding improvements in the organs and 
apparatuses. In those invertebrata which have no circulatory system (the 
nutritive fluids from the digestive cavity simply permeating the structure of 
the body), special organs and apparatuses are absent. In the invertebrate 
animals in which the circulatory system communicates directly with the 
digestive cavity, and contains a fluid differing in no essential respect from the 
digested matters of the stomach, the glandular and nervous systems do not 
exist, or are imperfectly developed. The closure of the circulatory system 
from the gastric cavity is attended by an improvement of the chemical and 
physical properties of the blood, and a corresponding improvement of the 
organs and apparatuses. In those animals having the most perfect circu- 
latory system, and the most highly elaborated blood, do we find the greatest 
perfection of the nervous, muscular, and organic systems. 

2. As the organs and apparatuses of the animal economy are developed and 
perfected, the necessity for a vigorous circulation of the nutritive materials 
becomes more urgent. As the temperature, intelligence, and activity of ani- 
mals, with their corresponding physical and chemical metamorphoses of the 
elements of organic structure, increase, there is a corresponding necessity for 
a rapid supply of those materials by ivhich the icastes may be repaired, and 
from which the various secretions and excretions may be elaborated and sepa- 
rated. The investigations upon the size of the heart and rapidity of the cir- 
culation, the perfection of the respiratory system, and the rapidity of its 
action, demonstrated conclusively that as the fluids and solids became more 
highly elaborated and developed, the action of the circulatory and respiratory 
systems became correspondingly rapid and vigorous. 

3. The bloodvessel system makes its appearance before the formation of a 
heart. The same fact may be noticed in the development of the foetus in 
warm-blooded animals. The motion of the fluid in this system, in some indi- 
viduals of the invertebrate animals, is effected by the contraction of the walls 
of its vessels; in others, by the motion of cilia? lining the walls of the ves- 
sels ; in others, by the irregular contractions of the body ; and in others, 
again, by an unknown force. The circulation of the blood in the stem of 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 43 

colonial polyps cannot be explained by a contraction of the walls of the ves- 
sels, or by the motions of the animal. 

These facts show that the existence of the heart is not essential to the 
motion of the blood. This remark applies, also, to the motion of the blood 
in the capillaries of higher animals. When the capillaries of a living ani- 
mal are placed under the microscope, the blood corpuscles do not always move 
in the same direction. It is stated by physiologists, that if the blood of a 
warm-blooded animal be abstracted, and deprived of its fibrin, and then in- 
jected into the circulatory system, it will not circulate in the capillary system. 
The animal will die, and if examined after death, the capillaries will be found 
congested with blood. This fact demonstrates conclusively, that the circu- 
lation of the blood in the capillaries is dependent, in a great measure, on the 
heart's action, and a mutual reaction takes place between the blood and capil- 
laries, and unless the circulatory fluid possess certain definite physical and 
chemical properties, the capillaries will not perform their office. 

4. The blood, with its corpuscles, exists in many invertebrata which are 
without any special organs. The same fact has been noticed in the develop- 
ment of the foetus of warm-blooded animals. A vascular system, circulating 
blood-corpuscles, exists before the formation of any special organs. These 
facts show that the primary origin of the blood-corpuscles, in both inverte- 
brate and vertebrate animals, is independent of any special organs. 

5. A progressive development of the different constituents of the blood 
may be traced in the animal kingdom. In the blood of the lowest inverte- 
brate animals, we find simple granules, analogous to those which are found 
in the blood and organs of all animals, when nutrition and growth are active. 
In the more highly organized, granular cells, analogous to the colourless cor- 
puscles of the vertebrata. In the most highly organized invertebrata, colour- 
less nucleated cells, analogous to the coloured corpuscles of Fishes, Reptiles, 
and Birds. In the three lowest classes of vertebrate animals, the coloured 
corpuscles are nucleated. This form also exists in the foetus of the mamma- 
lia ; it is, however, a transient condition, and the coloured corpuscles of the 
adult mammalia are without nuclei. The proportion of the albumen, and the 
perfection of the fibrin, varies with the development of an animal. 

6. The office of the blood-corpuscle in the invertebrata, appears to be 
rather the elaboration of the nutritive elements than the conveyance of oxy- 
gen. Mr. Newport observed, that in the insects, the blood-corpuscles are 
most numerous in the larva at the period immediately preceding each change 
of the skin. The blood, also, is more coagulable, and possesses a greater 
formative power. The blood, examined after the formation of the skin, con- 
tains corpuscles in much fewer numbers, and is far less rich in nutritive mat- 
ters. The same increase in numbers, and rapid consumption of the blood- 
corpuscles, is observed in the pupa state during the active development of 
the new parts which constitute the perfect insect. After the completion 



44 Jones, Investigations on the Solids and Fluids of Animals. [July 



of the perfect insect, only a few corpuscles remain, and most of the plastic 
elements of the blood have been withdrawn during the formative process. 

7. The spleen is absent from all invertebrate animals, without exception. 
It is also absent from the Amphioxus, the connecting link between the Fishes 
and the higher forms of Mollusca. In the Amphioxus and invertebrate 
animals, the blood-corpuscles are always colourless. The appearance of the 
spleen is accompanied by a change in the colour of the blood. Has the 
spleen anything to do with the production of the red colour of the corpuscles 
of vertebrate animals ? The appearance of the spleen in vertebrate animals 
is accompanied by an improvement of all their organs, apparatuses, and nutri- 
tive fluids. This little organ is the herald, rather than the cause of these 
great changes. Its presence indicates a higher development of organization. 

8. The improvement in the solids and fluids of organized beings occurring 
simultaneously, it is impossible to determine which system was the cause of 
the development of the other. In every individual of the animal kingdom, 
the component parts are mutually dependent upon each other. It would be 
impossible for a highly developed nervous system to exist without a corre- 
spondingly developed circulatory apparatus to supply it with blood, and 
organs to elaborate that blood, and remove from it all noxious compounds. 
These facts show clearly the necessity for the existence of a force distinct 

from nervous, chemical, and physical forces, which presides over the mole- 
cules of matter, controlling and directing their chemical and physical laws 
and affinities, thus moulding shapeless masses into definite forms. The de- 
velopment and perfection of each organ and apparatus and individual being 
depends upon the peculiar endowments of this vital or organizing force. The 
creation of a force, by whose modifications the physical, chemical, and vital 
constitution of every living being on earth, in air or water, is precisely adapted 
to fulfil certain definite ends, necessarily presupposes a Creator, who con- 
structed, comprehended, and controlled all the physical, chemical, and vital 
laws which regulate the universe. 

9. The operations of nature are carried on upon the same great plan, no 
matter how simple or complex be the animal. Cold-blooded animals are 
such, not from any peculiar chemical or physical endowments of the organic 
and inorganic molecules of their bodies, but from the peculiarity of the 
structure of their circulatory and respiratory systems. The perfection of 
these two systems may be taken as the index of the rapidity of the physical 
and chemical changes of the molecules of their fluids and solids ; and the 
intelligence and activity of the life actions are exactly proportional to the 
rapidity and amount of the physical and chemical changes of the organic and 
inorganic molecules. Modifications in the vital phenomena are accomplished 
by peculiar modifications of the structure and arrangements of the various 
organs and apparatuses, and by peculiar applications of the forces, 'and not 
by a suspension or alteration of the physical and chemical laws which govern 
all matter. 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 



45 



Colouring matters 



Fats 



III. Blood of Vertebrate Animals in its Normal Condition.* — The blood 
is a highly complex fluid ; this will be readily seen by an inspection of this 
table, drawn up by Simon : 

Water, 
r Fibrin. 
Protein compounds < Albumen. 

I Globulin. 
Hsematin. 
Hasmaphaein. 
Alcohol-extract. 
Extractive matters -{ Spirit-extract. 

"Water-extract. 
Cholesterin. 
Serolin. 

Red and white solid fats, containing phosphorus. 
Margaric acid. 
Oleic acid. 
Iron (peroxide). 
Albuminate of soda. 
Phosphates of lime, magnesia, and soda. 
Sulphate of potash. 

Carbonates of lime, magnesia, and soda. 
I Chlorides of sodium and potassium. 
J Lactate of soda. 
I Oleate and margarate of soda, 
r Oxygen. 
< Nitrogen, 
t- Carbonic acid. 
Sulphur. 
Phosphorus. 

Traces of the following substances have also been detected in the blood in 
certain pathological states of the system : — 
Sugar, 



Salts 



Gases 



Urea, 

Bilin, and its acids (?) 

Biliphaein, 

Glutin (?) 

Haemacyanin, 

Erythrogen, 

Hydrochlorate of ammonia, 
Acetate of soda, 



Urate of soda, 
Urate of potassa, 
Uric acid, 
Benzoate of soda, 
Margarin, 
Olein, 
Copper, 
Manganese, 
Silica. 



1 Our limits will not permit an extended discussion of the various methods em- 
ployed by different authors. Those who wish to investigate this subject for them- 
selves, will find much useful information in Simon's Chemistry of Man, p. 142, Philad., 
1846 ; Lehmann's Physiological Chemistry, translated by G. E. Day, and edited by 
Prof. Rogers, vol. i., pp. 541-648, Philad., 1855; Bowman's Medical Chemistry, pp. 
145-194, Philad., 1850. 

No. LXIIL— July 1856. 4 



46 Jones, Investigations on the Solids and Fluids of Animals. 



In investigations upon cold-blooded animals, it will be utterly impossible 
to determine all, or even a majority of these constituents, owing to the small 
amount of blood (often not more than 100 grains) which can, with the 
greatest care, be obtained from each individual. 

As little or nothing has been done in the study of the fluids of these ani- 
mals, it was necessary first to determine the most important constituents. 
The following is a brief statement of the method which I employed to deter- 
mine the — 

Water, 

Solid matters of blood, 
" " serum, 
Moist blood-corpuscles, 
Water of moist blood-corpuscles, 
Solid matters of moist blood-corpuscles, 
Liquor sanguinis, 
Water of liquor sanguinis, 
Solid matters of liquor sanguinis, 
Albumen and extractive matters, 
Fibrin, 

Fixed saline constituents. 

a. Receive into a porcelain capsule, capable of containing about f ^ss, the 
weight of which had been previously carefully ascertained and noted, from 
25 to 50. grains of blood. 

b. Fill a 100 gr. specific gravity bottle carefully with blood. 

c. Receive the remainder of the blood into a porcelain capsule (weight 
previously ascertained and noted) capable of containing about 500 grains of 
blood. In the majority of reptiles, and small birds and mammals, the blood 
will have been exhausted after the filling of the last vessel. Ascertain the 
weight of the capsule (a), with its blood, carefully, upon a delicate balance, 
and subtracting from this the weight of the capsule, we have remaining the 
weight of the blood. Place it upon a chloride of calcium bath, and subject 
it to a temperature of from 220° to 230° F. until it ceases to lose weight on 
being weighed at intervals of half an hour or an hour, the outside being care- 
fully wiped clean and dry each time. Subtracting the weight of the porce- 
lain capsule from the last weight, we obtain the amount of solid matters in 
the portion of blood evaporated; and subtracting the solid matters from the 
amount of blood used, we ascertain the amount of water. To ascertain the 
amount of water and solid matters in 1000 parts of blood, we use the follow- 
ing proportion : — 

Weight of \ ( Weight of C Proportion of solid matter l 

blood L : 4 dry I : : 1000 : 1 in 1000 parts of the I 
evaporated J ( residue J ■ { blood. J 

Having obtained the amount of solid matters in 1000 parts of blood, the 
amount of water may be determined by simply subtracting the solid matters 
from 1000. Next incinerate carefully the solid residue in a porcelain or 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 



47 



platinum crucible until all the carbonaceous matters are destroyed, and a light 
red or yellow ash remains behind. A high heat, and much care is needed in 
this tedious process. Another method recommended by Prof. Kogers, of the 
University, is to treat the dried residue with nitric acid, and gradually boil- 
ing down, incinerate. The organic matters pass of readily in the form of 
gases. A crucible of porcelain is to be preferred to one of platinum. The 
proportion of fixed saline matters in 1000 parts of bipod may be calculated 
in the following manner : — 

(Weight of 1 ( Weight of ash ~\ f Proportion of fixed saline ~\ 

blood L : J after incine- I : : 1000 : A matter in 1000 parts of I 
evaporated J ( ration J (. blood. j 

From this first portion of blood we have now obtained — 

Water of 1000 parts of blood. 
Solid matters of 1000 parts of blood. 
Fixed saline matter of 1000 parts of blood. 

b. Determine accurately upon the balance, the specific gravity of the blood. 
This should be done immediately after the porcelain capsule containing the 
blood was placed upon the chloride of calcium bath. 

c. Ascertain the weight of the porcelain capsule and the last portions 
of blood, and, subtracting the weight of the porcelain capsule, we have re- 
maining that of the blood. Set it aside until the blood is completely coagu- 
lated, and the serum separated from the clot j the length of time required 
for this varies with the animal. Ascertain the specific gravity of the serum 
in the 100 gr. sp. gr. bottle. Pour into a porcelain capsule (weight pre- 
viously noted) from 20 to 50 grains of serum, and evaporate upon the chlo- 
ride of calcium bath until it ceases to lose weight. The water, solid matters, 
and fixed saline constituents in 1000 parts of serum, may be ascertained in a 
manner exactly similar to that by which these ingredients were determined 
in 1000 parts of blood. It is also necessary to ascertain the amount of solid 
matters in the serum of 1000 parts of blood. Knowing the quantity of 
water in 1000 parts of blood, and assuming that the water of the blood 
exists wholly in the form of serum — knowing, also, the amount of water and 
solid matters contained in a given portion of serum, we may, from the quan- 
tity of water in the blood, estimate the quantity of solids held in solution in 
the serum, thus — • 

f Weight of water in") ( Weight of solid mat- ~) ( Water in 1000 ~) C Solids of serum in ) 
j the quantity of V : < ter in the quantity £ : : < parts of the > : < 1000 parts of > 
(_ serum employed ) (of serum employed ) ( blood ) ( the blood. ) 

This is not absolutely correct, and all physiological chemists have failed to 
ascertain with absolute accuracy the amount of solid matters in the serum of 
1000 parts of blood. The error, however, is very small, and cannot be 
avoided. 

The clot which remained after the removal of the serum, is next cut 
into thin slices, and inclosed in a muslin bag, and carefully washed under 



48 Jones, Investigations on the Solids and Fluids of Animals. [July 



a stream of water until the fibrin remains in the bag, free from serum and 
blood-corpuscles, and almost colourless. Another method of obtaining the 
fibrin, is to receive into a small glass bottle (capable of containing from f Jij 
to f^iv) a portion of blood, and then dropping in some dozen small strips of 
lead, and closing with the stopper, agitate and shake until the fibrin coagu- 
lates around the lead-strips. 

Two strong objections lie against the employment of this method in inves- 
tigations upon cold-blooded animals: 1. Their blood, in most cases, cannot 
be obtained in sufiicient quantities; and 2, the fibrin is so soft that it will 
not coagulate around the lead-strips. The clean fibrin is then placed in a 
small evaporating dish, and dried upon the chloride of calcium bath, at a tem- 
perature of 220° to 230° F., until it ceases to lose weight. If we wish still 
greater accuracy, it may be treated with dilute hydrochloric acid, absolute 
alcohol, and ether, to dissolve out the saline and fatty and extractive matters 
before evaporation upon the chloride of calcium bath. 

After having obtained the weight of dried fibrin in the quantity of blood 
used in the experiment, the proportion in 1000 parts of blood may be deter- 
mined by the following calculation : — 

f Weight of ) f Weight of ) ( Quantity of fibrin 

■j blood V : J fibrin L : : 1000 : \ in 1000 parts of 
( employed J ( obtained J ( blood. 

From the third portion of blood (c) we have thus obtained the following 
constituents : — 1 

Water in 1000 parts of serum. 

Solid matter in 1000 parts of serum. 

Solid matters in serum of 1000 parts of blood. 

Albumen and extractive matter. 

Fixed saline constituents in 1000 parts of serum. 

Fibrin in 1000 parts of blood. 

We have now sufiicient data from which to calculate the dried blood-cor- 
puscles, moist blood- corpuscles, and liquor sanguinis. To ascertain the 
weight of the dried blood-corpuscles, add together the weights of the fibrin 
and the solids of the serum contained in 1000 parts of blood, and deducting 
the sum of them from the weight of the entire solid matter, which consists of 
fibrin, solids of the serum, and corpuscles, the difference therefore will repre- 
sent the proportion of the latter in 1000 parts of the blood. Another me- 
thod is founded upon the fact that a solution of Glauber's salts possesses the 
property of rendering the blood-corpuscles capable of being retained upon a 
filter. This method has been applied by Figuier, Dumas, and Hofle. 

Defibrinated blood is treated with eight times its volume of a concentrated 

1 If the fixed saline constituents of serum of 1000 parts of blood be subtracted 
from the solid matters of the serum of 1000 parts of blood, we have remaining the 
albumen and extractive matters. 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 49 

solution of Glauber's salts, and filtered; the residue on the filter is rinsed 
with the same solution; a stream of oxygen is passed through the mass lying 
on the filter at the same time; and finally, the mass of blood-cells is either 
coagulated with hot water upon the filter, or washed off into tepid water, and 
coagulated by boiling. This method, although apparently practicable and 
accurate in theory, is not to be depended upon in practice, because some of 
the blood-corpuscles always pass through the filter, and it is impossible to 
determine whether all the serum is actually separated in this manner ; and 
also the solution of the Glauber's salts passes into the corpuscles by endos- 
mosis, whilst the organic constituents of the corpuscles must pass out. 

Simon's method of finding the quantity of the blood-corpuscles directly, is 
also altogether wanting in accuracy. C. Schmidt, to whose intelligence and 
indefatigable researches physiological chemistry is indebted for many brilliant 
discoveries, first attempted to determine the relation of the moist blood-cells to 
the intercellular fluid, or liquor sanguinis. He found by laborious researches, 
that the constant factor, by which we may calculate the moist blood-cells from 
the dry blood-corpuscles, was 4. If we multiply the number of dry blood- 
corpuscles by 4, we obtain the quantity of fresh blood-cells; subtracting these 
from 1000, we have remaining the amount of liquor sanguinis in 1000 parts 
of blood. 

We will now proceed to consider the results of our investigations without 
stopping to consider those innumerable little steps of caution and accuracy 
which would naturally suggest themselves to every intelligent and careful 
observer during an organic analysis. I have arranged the results in as con- 
densed a form as possible, so that the facts and principles developed may be 
evident at a glance. 

Amounts of blood in different animals. — Great discrepancies have pre- 
vailed amongst physiologists with regard to the amount of blood contained in 
the bodies of animals. Blumenbach estimated the quantity in an adult man 
at 8.5 to 11 pounds, and Reil at 44 pounds. M. Valentin, by his method of 
injecting water into the bloodvessels during life, arrived at the following re- 
sults. The numbers represent the relations existing between the quantity of 
blood and the weights of the body. 

Large dogs, as . . 1 : 4.5 (the mean of four experiments.) 

A lean, debilitated sheep 1 : 5.02 

Cats (female) . . 1 : 5.78 (the mean of two experiments.) 

Large female rabbit . 1 : 6.20 

From these data he estimated the amount of human blood to be — 

Male sex 1 : 4.36 
Female sex 1 : 4.93 

At the present day, the blood is generally estimated at 22 pounds, which 
is equal to about the eighth part of the weight of the entire human body. 



50 Jones, Investigations on the Solids and Fluids of Animals. [July 



Lehmann determined the amount of blood in the bodies of two criminals who 
were decapitated, to be nearly one-eighth of that of the whole body. 

By numerous careful examinations of cold-blooded animals, I have arrived 
at the following results, which must be considered only as an approximation 
to the truth : — 

Amount of blood in Ophidians ^ to T ^ of the weight of the whole body. 
" Emys terrapin T ' t to T ] 5 " " 

" Emys serrata T ^ to T V " " " 

" " Testudo polyphemus T ] 5 to 7 V " " " 

These results shoiv that the blood is far less abundant in cold than in 
icarm-blooded animals. This fact is important, as it will aid us in the ex- 
planation of the differences which distinguish the two great classes of animals. 

In all the cold-blooded animals which I have thus far examined, the portions 
of blood first drawn coagulate more slowly than those drawn last. 

Owing to the admixture of venous and arterial blood in the common ven- 
tricle of the heart of these animals, their arterial blood is never of that bright 
red colour of the arterial blood of warm-blooded animals, but is of a dark red 
colour, intermediate between that of arterial and venous blood. 

The colour of the serum in most Reptiles, as Ophidians, Batrachians, Fishes, 
and some Chelonians — as the Gopher — is of a light yellow colour. In the 
Yellow-belly Terrapin {Emys serrata), Chicken Terrapin [Emys reticulata), and 
Salt-water Terrapin {Emys terrapin), the serum is of a golden colour. 

The strong smell of both cold and warm-blooded animals appears to reside 
especially in the serum, and may be developed by treating the serum with a little 
sulphuric acid, and a gentle heat. I have demonstrated this fact in numerous 
instances, and often in the serum of disagreeable animals, with disgusting 
power. 

The following table represents the specific gravities of the blood of dif- 
ferent animals, which were accurately determined upon a delicate balance; 
and we would here state, that the balance which was used in all my analyses 
was capable of turning to T qVo °f a g ra i n « 





Specific gravity. 


Blood of Coach-whip Snake (Psdmmophis flagellifdrmis) 


1036. 


" female Alligator {Alligator Mississippiensis) 


1046. 


" Loggerhead Turtle ( CheUnia caritta) 


1032.5 


" Alligator Cooter ( Chelonura serpentina) 


1025.5 


" female Salt-water Terrapin [Emys terrapin) 


1035.3 


" Chicken Terrapin [Emys reticulata) . 


1034. 


" female Yellow-belly Terrapin (Emys serrdta) 


1026.5 


" male Gopher ( Testudo polyphemus) 


1030. 


" female Night Heron (Ardea nyciicorax) 


1028. 




1043.6 


" common Cur Dog 


.1045.5 


r mean 


1051.5 


" pregnant women, by Becquerel and Rodier < max. 


1055.1 


( min. 


1046.2 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 



51 



Blood of 20 persons, by Becquerel and Rodier, mean 

10 " " " mean 

11 11 men " " mean 

11 8 females " " mean 



Specific gravity 

1055. 
1056.0 
1060.2 
1057.5 



Table of the Specif c Gravities of the Serum of different Animals. 



Serum of Loggerhead Turtle ( Chelonia care'tta) 

" Alligator Cooter ( Chelonura serpentina) 

" Salt-water Terrapin {Emys terrapin) . 

" Yellow-belly Terrapin [Emys serrdta) 

" Yellow-belly Terrapin [Emys serrdta) 

" male Gopher {Testudo polyphemus) . 

" male Gopher {Testudo polyphemus) 

" common Cur Dog .... 



11 men, by Becquerel and Rodier 



8 females 



r mean 
1 maximum 
I minimum 
mean 
maximum 
minimum 



8 human (Lehmann) 



1014.8 

1013.6 

1012.7 

1013.7 

1014. 

1018. 

1017. 

1030.5 

1028.0 

1030.0 

1027.0 

1027.4 

1030.0 

1026.0 

1028. 



From these tables we learn that, as the organs and apparatuses, and intelli- 
gence of animals are developed, the blood becomes more concentrated. 



Table showing the Amount of Water in 1000 parts of the Blood of different 

Animals. 

Cold-blooded Animals. 



Blood of Invertebrate Animals. 

Water in 1000 

Name of observer. Name of animal. parts of blood, 

C. Schmidt. Pond Mussel (Anodonta cygnea) . . . 999.146 

Harless and Bibra. Shell Snail {Helix pomatia) .... 985.482 

Cephalopods {Loligo and Eledone) . . . 992.67 

Blood of Vertebrate Animals. 

■ . FISHES. 

Jos. Jones. Stingray {Trygon sabina) .... 884.20 

" Hammerhead Shark {Zygoma mdlleus) . . 861.14 

" Garfish {Lepisosteus osseus) .... 886.70 

J. F. Simon. Carp . .■ 872.00 

Tench 900.00 

Dumas and Prevost. Trout . . . . . . . . 863.70 

Eelpout ........ 886.20 

Eel . ....... 846.00 



52 Jones, Investigations on the Solids and Fluids of Animals. [July 



AQUATIC REPTILES. 



Name of observer. 

Jos. Jones. 

Dumas and Prevost. 

Jos. Jones. 



J. F. Simon. 
Jos. Jones. 



Nasse. 

Dumas and Prevost. 

it tt 

a tt 

u tt 

tt tc 

Jos. Jones. 



Andral, Gavarret, 
and Delafond. 

Nasse. 

Dumas and Prevost. 

Andral, Gavarret, 
and Delafond. 

Nasse. 

Dumas and Prevost. 
And., Gav., andDeia. 
Nasse. 

Dumas and Prevost. 
<« « 

Nasse. 

And., Gav., andDeia. 



Name of animal. 

Bullfrog (Rdna pipiens) . 

Frog 

Loggerhead Turtle ( Cheldnia care'tta) 
Alligator Cooter ( Chelonilra serpentina) 
Salt-water Terrapin (Emys terrapin) 
Chicken Terrapin [Emys reticuldta) 
Yellow-belly Terrapin [Emys serrdta) 
Alligator {Alligator MississippUnsis) 

LAND REPTILES. 

Bufo variabilis .... 
Hognose Viper (HeUrodon platyrhinos) 
Black Viper (Hetirodon niger) . 
Coach-whip Snake (Psdmmophis fiagellifd: 
Black-Snake ( Coluber constrictor) 
Gopher ( Testudo polyphemus) . 

Warm-blooded Animals. 
Blood of Birds. 

Goose 
Hen . 
Hen. 
Pigeon 
Duck 
Raven 
Heron 

Heron (Ardea nycticorax) 
Hooting Owl (Syrnium nebuUsum) 
' Black Turkey-buzzard ( Cathdrtes atrdtus) 

Blood of Mammalia, 
f mean 
17 Horses < maximum 
I minimum 

Horse 
Horse 

r mean 
14 Cattle < maximum 
(. minimum 

Ox . . 
Calf . 

30 Sheep (mean) 
Swine 
Rabbit 
Rabbit 
Goat 
Goat 

16 Dogs (mean) 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 



53 



Name of observer. 

Nasse. 

Dumas and Prevost. 
Jos. Jones. 

Dumas and Prevost. 
Nasse. 

M. Lecanu. 



Name of animal 

Dog . . 

Dog 

Common Cur-Dog 
Common Cur-Dog 
Cat 
Cat 



Man 



maximum 
minimum 
mean 



Water in 1000 
parts of blood. 

790.50 

810.70 

811.87 

806.52 

795.30 

810.02 

853.135 

778.625 

815.880 



Table of the Solid Matters in 1000 parts of the Blood of different Animals. 

Cold-blooded Animals. 
Blood of Invertebrate Animals. 

Name of observer. Name of animal. 

C. Schmidt. Pond Mussel (Anodonta cygnea) . 

Harless and Bibra. Shell Snail [Helix pomatia) . 

" " Cephalopods (Loligo and Eledone) . 

Blood of Vertebrate Animals. 

FISHES. 



Jos. Jones. 


Stingray ( Trygon sabina) . ' . 


115.80 


a tt 


Hammerhead Shark (Zygoma mdlleus) . 


138.86 


** • . i ** 


Garfish (Lepis6steus dsseus) .... 


113.30 


J. F. Simon. 


Carp . - . • , 


128.00 


tt 


Tench ...... . . . 


100.00 


Dumas and Prevost. 


Trout . • • . . . j- . . . . 


136.30 




Eelpout 


113.80 


<( <« 


Eel 


154.00 




AQUATIC REPTILES. 




Jos. Jones. 


Bullfrog (Rana pipiens) .... 


167.49 


Dumas and Prevost. 




115 40 


Jos. Jones. 


Loggerhead Turtle ( CheUnia care'tta) . 


120.81 


«< 


Alligator Cooter ( Chelonura serpentina) 


105.00 


u 


Salt-water Terrapin (Emys terrapin) 


154.72 


tt 


Chicken Terrapin (Emys reticulata) 


153.02 


it 


Yellow-belly Terrapin (Emys serrdta) . 


124.59 


it 


Alligator (Alligator Mississippiensis) 


176.14 




LAND REPTILES. 




J. F. Simon. 


Bufo variabilis 


151.80 


Jos. Jones. 


Hognose Viper (Heterodon platyrhinos) 


166.76 


n 


Black Yiper (Heterodon niger) 


139.43 




Coach-whip Snake (Psdrnmophis flagellif6rmis) 


181.70 


«< 


Black-Snake ( Cdluber constrictor) . 


211.37 


tt 


Gopher (Testudo polyphe'mus) 


156.62 



Solid matters 
in 1000 parts 
of blood. 

0.854 
14.518 
7.33 



54 Jones, Investigations on the Solids and Fluids of Animals. [July 



Name of observer, 

Nasse. 



Warm-blooded Animals. 
Blood of Birds. 

Name of animal. 



Goose 
Hen 

Dumas and Prevost. Hen 

Pigeon 
Duck 
Raven 
Heron 

Jos. Jones. Heron [Ardea nycticorax) 

" Hooting Owl [Syrnium nebuldsum) 

Black Turkey -buzzard [Cathdries atrutus) 



Andral, Gavarret, 
and Delafond. 

Nasse. 

Dumas and Prevost. 

Andral, Gavarret, 
and Delafond. 

Nasse. 

Dumas and Prevost. 
And., Gav., andDela. 



17 horses 

Horse 
Horse 



Blood of Mammalia. 
mean . 
maximum 
minimum 



14 Cattle 



mean . 

maximum 

minimum 



Dumas and Prevost. 
<< « 

Nasse. 

And., Gav., and Dela. 
Nasse. 

Dumas and Prevost. 

Jos. Jones. 
it 

Dumas and Prevost. 
Nasse. 

M. Lecanu. 



Ox. . . 

Calf 

30 Sheep (mean) 

Swine 

Rabbit . 

Rabbit . 

Goat 

Goat 

16 dogs (mean) 
Dog . . 
Dog 

Common Cur-Dog 
Common Cur-Dog 
Cat . 

Cat 

c maximum 
Man -l minimum 
mean . 



Solid matters 
in 1000 parts 
of blood. 



A careful comparison of these results leads to the following conclusions : — 

1. The proportion of water is greatest in the invertebrata. The blood of 
these animals has a specific gravity not much above that of common water. 
The specific gravity of the blood of Limulus Cyclops, according to'Grenth, is 
only 1010.317. 

2. Amongst vertebrate animals, the amount of water existing in the blood is 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 55 

greatest in Fishes and aquatic Reptiles, and least in Serpents, Birds, and Mam- 
malia. As a necessary consequence, the solid matters of the blood are less 
in the invertebrata, fishes, and aquatic reptiles, and greatest in serpents, 
birds, and mammalia. 

3. It may he laid down as a general law, that as the organs and appara- 
tuses of the animal economy are developed, and the temperature and intellect 
correspondingly increased, the blood becomes richer in organic constituents. 
The blood of Serpents appears at first sight to form an exception. The 
large amount of solid matters, however, existing in their blood, is readily 
accounted for when we consider their habits. These reptiles seldom or never 
drink water; consequently the fluids of their bodies are derived from the 
animals which they consume. In all animals, the water of the blood and 
tissues is continually evaporating from the surface of the lungs and body. 
The amount of evaporation is in proportion to the structure, habits, and tem- 
perature of animals, and the temperature and moisture of the atmosphere. It 
is greatest in warm-blooded animals, and in hot and dry climates. Amongst 
cold-blooded animals it is greatest in those having naked skins, and least in 
those covered by scales, bone, and horn. No matter how slow and small 
this evaporation, if it be not counteracted by a corresponding supply of water, 
the blood necessarily becomes concentrated, and yields a larger proportion of 
solid constituents upon analysis. 

4. Our knowledge is as yet too limited to develop any laws respecting 
the amount of water and solid constituents which characterize the blood of 
each species and genus. By comparing the analyses of the blood of the Mam- 
malia, we see that the proportions of its constituents vary as much in indi- 
viduals of the same species as in individuals of remotely separated genera. 

We will next consider the amounts and constitutions of the moist blood- 
cells, and liquor sanguinis. 



Table of the Moist Blood- Corpuscles, and their Constituents in 1000 parts of 

Blood. 



Name of animal. 


Moist Wood-cor- 
puscles in 
1000 parts of 
blood. 


Water in moist 
blood-corpus- 
cles in 1000 
parts of blood. 


Solid matter in 
moist blood- 
corpuscles in 
1000 parts of 
blood. 


Shark [Zygoma malleus) 


. 293.44 


220.08 


73.36 


Garfish (Lepisdsteus dsseus) . 


. 229.00 


171.75 


57.25 


Trout . . .... 


. 275.20 


206.40 


68.80 


Eelpout .... 


. 192.40 


144.30 


48.10 


Eel 


. 240.00 


180.00 


60.00 


Bullfrog (Rana pipiens) 


. 450.12 


337.59 


112.53 


Frog . . . . . 


. 276.00 


207.00 


69.00 


Hognose Viper (Heterodon plat.) 


. 444.84 


333.63 


111.21 


Black Viper [Heterodon niger) 


. . 270.40 


202.80 


67.60 


Coach-whip Snake (Psdmmophis 


flagel- 






lifdrmis) 


. 488.80 


366.60 


122.20 



56 Jones, Investigations on the Solids and Fluids of Animals. [July 



Moist blood-cor- Water in moist Solid matter in 



Name of animal. 


puscles in 
1000 parts of 
blood. 


blood-corpus- 
cles in 1000 
parts of blood. 


moist blood- 
corpuscles in 
1000 parts of 
blood. 


Black-Snake ( Cdluber constrictor) 


. 469.20 


351.90 


117.30 


Turtle ( Cheldnia care'tta) 


. 289.52 


217.14 


72.38 


Alligator Cooter ( Chelonura serpentina) 


. 235.40 


176.55 


58.85 


Salt-water Terrapin ( Emys terrapin) 


. 447.28 


335.46 


111.82 


Chicken Terrapin [Emys reticulata) 


. 372.00 


279.00 


93.00 


Yellow-belly Terrapin {Emys serrdta) 


. 336.76 


252.57 


84.19 


Gopher (Testudo poly phe'mus) 


. 393.56 


302.67 


90.89 


Alligator [ Alligator Mississippie'nsis) 


. 364.08 


273.06 


91.02 


Goose . . . . 


. 485.80 


364.35 


121.45 


Hen 


. 579.00 


434.25 


144.75 


Hen 


. 628.40 


461.30 


157.10 


Duck 


. 600.40 


450.30 


150.10 


Pigeon 


. 622.80 


467.10 


155.70 


Haven 


. 586.40 


339.80 


146.60 


Heron . . w 


. 530.40 


367.80 


132.60 


Heron (Ardea nycticorax) 


. 315.84 


236.88 


78.96 


Hooting Owl (Syrnium nebuldsum) 


. 427.36 


320.52 


106.84 


Black Buzzard (Cathdrtes atrdtus) 


. 626.88 


470.16 


156.72 


\ mean .... 


. 411.60 


308.70 


102.90 


17 Horses > maximum . 


. 448.40 


336.30 


112.10 


) minimum 


. 326.00 


244.50 


81.50 


Horse ...... 


. 468-52 


351.39 


117.13 


30 Sheep (mean) . . . . 


. 404.40 


303.30 


101.10 


Sheep ...... 


. 369.68 


277.26 


92.42 


~\ mean .... 


. 398.80 


299.10 


99.70 


14 Cattle > maximum . . . 


. 468.40 


351.30 


117.10 


J minimum 


. 340.40 


255.30 


85.10 


6 Swine, English breed (mean) 


. 422.80 


317.10 


105.70 


1 mean .... 


. 593.20 


444.90 


148.30 


16 Dogs > maximum . 


. 706.40 


529.80 


176.60 


J minimum 


. 509.20 


387.90 


121.30 


Common Cur-Dog .... 


. 363.64 


197.73 


65.91 


Common Cur-Dog .... 


. 322.76 


242.07 


80.69 



Table of the Liquor Sanguinis and its Constituents in 1000 parts of Blood. 



Name of 
observer. 



Name of animal. 



Jos. Jones. Shark [Zygoma malleus) 

" Garfish (Lepisosteus osseus) . 

" Bullfrog (Rdna pipiens) 

" Hognose Viper (Heterodon platyr- 

hinos) 

" Black Viper (Heterodon niger) 

Coach-whip Snake (Psdmmophis 
jlagellifdrmis) . . . . 



Liquor 
sanguinis in 
1000 parts 
of blood. 

706.56 
771.00 
549.88 



555.16 
729.60 



Water 
in liquor 
sanguinis ir 
1000 parts 
of blood. 

641.06 
714.95 
494.92 



499.61 
657.77 



511.20 451.70 



Solid matter 
in liquor 

sanguinis in 
1000 parts 
of blood. 

65.50 
56.05 
54.90 



55.55 
71.83 

59.50 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 57 



Liquor "Water Solid matter 

. sanguinis in in liquor in liquor 

rs aHie oi Name of animal. 1000 parts sanguinis in sanguinis in 

observer. of blood. 1000 parts 1000 parts 

of blood. of blood. 

Jos. Jones. Black-Snake [Cdluber constrictor) 530.80 436.73 94.07 

Turtle ( CheUnia caretta) . . 710.49 662.05 48.43 

Alligator Cooter (Clielonura serpent) 764.60 718.45 46.15 

Salt-water Terrapin [Emys terrapin) 552.72 509.82 i 42.90 

Chicken Terrapin {Emys reticulata) 628.00 567.98 60.02 

Yellow-belly Terrapin (^wysserrafa) 663.24 622.84 40.40 

GoyheT {Testudo pohjphemus) . 606.44 540.71 65.73 

" Alligator [Alligator Mississippiensis) 635.92 550.80 85.12 

Heron (Ardea nycticorax) . . 684.16 636.01 48.15 

" Hooting Owl [Syrnium nebuUsum) 572.64 519.14 53.50 

Black Buzzard ( Cathdrtes atrdtus) 373.12 329.01 44.11 

Common Cur-Dog .... 736.36 613.14 125.22 

Common Cur-Dog .... 677.24 564.45 112.79 

The following general facts and conclusions have been derived from a 
careful comparison of the results of the examination of the important con- 
stituents of the blood of different animals : — 

In tlie invertebrata, the number of blood-corpuscles is very small in com- 
parison with the number which exists in the blood of the vertebrata. In this 
class, ice find only colourless corpuscles. In the Branchiostoma, or Am- 
phioxus, the connecting link between the highest orders of the invertebrata 
and Fishes, the blood, like that of invertebrate animals, contains only colour- 
less corpuscles, is exceedingly rich in water, and correspondingly poor in solid 
constituents. As the organs and apparatuses are developed, the blood is cor- 
respondingly improved. The increased development of the cerebrospinal 
system, and the organs of vertebrate animals, is attended by a corresponding 
increase in the number of the solitary gland-cells of the blood. In this class, 
the number of blood-corpuscles is, as a general rule, lowest in cold-blooded 
animals, and highest in Birds and Mammalia. There are, however, exceptions 
to this rule. I have found the number of blood-corpuscles in some cold- 
blooded animals, especially Serpents, higher than that of some Birds and Mam- 
mals. This statement, however, will be modified somewhat by the fact, that 
the whole amount of blood, and the absolute number of blood-corpuscles 
existing in the blood of cold-blooded animals, is much less than that which 
exists in the blood of warm-blooded animals. 

The following table contains some striking facts : — 

Blood- corpuscles in 1000 parts of blood. 



Bullfrog [Edna pipiens) 


108.68 


Salt-water Terrapin [Emys terrapin) . 


103.82 


Alligator [Alligdtor Mississippiensis) . 


86.39 


Hognose Viper [Eeteroclon platyrhinos) 


102.22 


Coach-whip Snake [Psdmmopliis fiagelliformis) . 


118.34 


Black-Snake [Cdluber constrictor) 


112.22 



58 Jones, Investigations on the Solids and Fluids of Animals. [July 



Heron (Ardea nycticorax) 74.91 

Owl [JSyrnium nebulosum) 101.08 

Horse . . . . . / . ( . . . 81.50 

Horse 102.90 

Goat . . ' 4 .1 . -'ft- ^ Sf ?^ 86 -°° 

Goat ... . 102.00 

Cur-Dog 62.72 

Cur-Dog 78.04 

Dog ......... 123.80 

Cow . . 85.10 



Notwithstanding the differences in the number of blood-corpuscles, the dif- 
ference of temperature was preserved, not only between the warm and cold- 
blooded animals, but also between the individual species of each class. The 
thermometer indicated a temperature of over 100° F., in the Heron having 
74.91 parts of blood-corpuscles, whilst in the Frog, Serpents, and Chelonians, 
having nearly double the number of blood-corpuscles in a given quantity of 
blood, the thermometer indicated a temperature several degrees below that 
of the surrounding medium. 

Several physiologists assert, that the sole office of the blood-corpuscle is to 
carry oxygen in, and convey carbonic acid gas out, of the animal economy. 
If this be true, the temperature of an animal should be determined, in great 
measure, by the number of its blood-corpuscles, for the temperature of the 
body is proportional to the amount of oxygen which enters the animal eco- 
nomy, and combines with the organic elements of its nutritive fluids and 
tissues. Many other facts might be mentioned, in addition to those which we 
have just mentioned, to prove that the sole office of the blood-corpuscles is 
not the introduction of oxygen, and the carrying out of carbonic acid. The 
following considerations will show that the serum of the blood is also active 
in the performance of these important offices : — 

In the capillaries and bloodvessels, the coloured corpuscles rush along in 
the centre of the streams, whilst pure serum, alone, is in contact with the walls 
of the vessels. In the capillaries of the lungs, the oxygen, from this arrange- 
ment, must necessarily be absorbed first by the serum. Again, in no case 
do we find the organic cells — the active agent in all secretion and excretion — 
in immediate contact with the blood-corpuscles. They are separated from 
them by the coats of the capillaries, and a structureless basement membrane. 
The same is true of the anatomical elements of the muscular tissue. From 
whence do they derive oxygen, a continuous supply of which is absolutely 
necessary for the life and activity of every living molecule of organic matter ? 

The same arguments will also prove that the blood-corpuscles are only 
secondary agents in the conveyance of carbonic acid gas out of the organs 
and tissues to the lungs. These conclusions can be sustained by numerous 
examples. Do we find blood-corpuscles in plants ? Do we find blood-cor- 
puscles in the lowest orders of invertebrate animals ? Spallanzani has long 



1856.] Jones, Investigations on the Solids and Fluids of Animals. 59 

since demonstrated that all organized bodies, whether living or dead, possess 
the property of absorbing oxygen, and giving out carbonic acid. 

What, then, are the principal offices of the blood-corpuscles? and what does 
an increase in their number denote ? These questions can only be answered 
by a consideration of their constitution and their relations with the liquor 
sanguinis by which they are surrounded. 

Each corpuscle is a cell, resembling in its nutrition, growth, and general 
structure the active agents in the formation, elaboration, and separation of 
all secretions and excretions. Their cell-walls possess the power of sepa- 
rating from the surrounding medium certain peculiar mineral and organic 
compounds. If a blood-corpuscle be placed in water, it swells up, and 
finally bursts. If it is placed in a dense solution, its contents pass out, 
and the cell-wall shrivels up. The same physical laws of endosmose and 
exosmose are at work in the animal economy. A mutual action and 
reaction is incessantly carried on between the interior fluid contents of 
the blood-corpuscles and the exterior liquor sanguinis. Whenever water, 
or liquids of low specific gravity, are introduced, they dilute the serum, 
and immediately there is an endosmose of the exterior less dense fluid into 
the denser contents of the corpuscle. When water is withheld, the liquor 
sanguinis continually loses this element by evaporation from the surface of 
the lungs and skin, and by the action of the kidneys, and becomes denser than 
the contents of the corpuscles, and exosmose takes place into the surrounding 
medium. The cell-wall modifies the physical and chemical properties and 
constitution of every molecule of liquor sanguinis that passes through its 
structure. The office, then, of the blood-corpuscles, taken collectively, is that of 
an immense gland, which elaborates the constituents of the blood. 

In the Mammalia we have an increase, not only by weight, but also an 
immense increase in numbers, of the blood-corpuscles, owing to their greatly 
diminished size, and the amount of secreting surface exposed to the intercellular 
fluid is correspondingly increased. This being the case, the blood of these 
animals must be more highly elaborated, and all their organs and apparatuses 
correspondingly developed. 

The solid residue of the liquor sanguinis is very small in the invertebrata. 
Amongst vertebrate animals it varies without reference to the species, genus, 
and class, and appears not to be influenced in its amount or chemical con- 
stitution by the development of animals. It is reasonable to suppose that it 
is dependent more immediately upon the character of the food. 

The fibrin presents a remarkable index of the vital organic and intellectual 
endowments of animals. In the whole of the invertebrate kingdom it is 
absent, except in a few of the most highly organized, in whom its appearance 
is accompanied by a corresponding improvement of the cerebro-spinal system, 
and all the organs. 

In the lowest orders of the vertebrata, as Fishes and Batrachians, it is soft, 
unstable, and readily convertible into albumen. 



60 Jones, Investigations on the Solids and Fluids of Animals. [July 



In the Ophidians and Chelonians, although it is stable and does not dis- 
solve, still its structure is soft, inconsistent, and resembles in many respects 
the fibrin which is formed when the vital forces of warm-blooded animals 
have been exhausted by copious and continued bleedings. 

Here we have a beautiful demonstration of the fact that the animal kingdom 
is constructed upon one great plan. Pathological conditions of the most highly 
organized animals are found to exist as the normal and permanent condi- 
tions of those placed below in the scale of creation. If the forces of a warm- 
blooded animal be reduced, it presents a condition in many respects similar 
to that of a cold-blooded animal. "We will illustrate this by one other exam- 
ple. Warm-blooded animals, in health, are able to maintain their tempera- 
ture at a fixed standard, regardless of that of the surrounding medium. As 
the surrounding temperature descends, the efforts of nature to sustain a 
definite degree of heat, increase. If, however, the forces of the animal 
economy be impaired, the efforts of nature are no longer sufficient to keep the 
body heated to the definite normal standard, and gradually the body assumes 
the temperature of the surrounding medium. The intellect and all the 
organic forces become torpid ; the chemical actions cease, or are performed 
in a feeble or perverted manner; and finally, the once active and warm- 
blooded animal is reduced to the condition of a sluggish cold-blooded animal. 
The following table represents the amount of fibrin in 1000 parts of the 
blood of different animals : — 



C. Schmidt. 
Jos. Jones. 



J. F. Simon. 



Jos. Jones. 
J. F. Simon 
Jos. Jones. 



Name of observer. 



Pond Mussel (Anodonta cygnea) 

Stingray ( Trygon sabina) 

Hammerhead Shark (Zygoma malleus) . 

Garfish (Lepisdsteus dssens) 

Carp -<Uwv''.* ; b<4vd v *:fr$&W&.-0{ **l 

Tench . . . . . 

Bullfrog {Edna pipiens) 

Bufo Variabilis 

Black Viper {Heterodon niger) 
Coach-whip Snake (Psdmmophis fiagellifo) 
Black-Snake ( Coluber constrictor) 
Loggerhead Turtle ( Cheldnia cardtta) 
Alligator Cooter (Chelonura serpentina) . 
Salt-water Terrapin (Emys terrapin) 
Chicken Terrapin [Emys reticulata) . . 
Yellow-belly Terrapin (Emys serrdta) 
Gopher (Testudo polypJidmus) . 
Alligator (Alligator Mississippidnsis) 

Goose 

Hen ....... 



Name of animal. 



Fibrin in 1000 
parts of blood. 

0.033 

, unstable 

. unstable 

. unstable 

. unstable 

, unstable 

. unstable 

. unstable 



Jos. Jones. 



Nasse. 



Heron (Ardea nycticorax) 

Hooting Owl (Syrnium nebuldsum) . 

Black Turkey-buzzard (Cathdrtes atrdtus) 



2.16 
1.88 
5.06 
2.61 
0.35 
4.15 
2.51 
1.04 
5.73 
3.07 
3.46 
4.67 
2.20 
4.69 
0.41 



185G.] Jones, Investigations on the Solids and Fluids of Animals. 61 



17 Horses 



Name of animal. 

mean 

maximum 

minimum 



Horse 



14 Cattle 



mean 

maximum 

minimum 



Ox 



Name of observer. 

Andral, Gavarret, 
and Delafond. 

Nasse. 

Andral, Gavarret, 
and Delafond. 

Nasse. 

And., Gav., andDela. 30 Sheep (mean 
Nasse. Swine 

And., Gav., andDela. 6 Swine (English breed), mean 
Nasse. Goat 
And., Gav., andDela. 16 Dogs (mean) 
Nasse. Dog 
Jos. Jones. Common Cur-Dog 

" Common Cur-Dog 

Nasse. Cat 

In addition to the observations which we have previously made, this table 
also shows that the fibrin is one of the most variable of all the constituents 
of the blood. This arises, in great measure, from imperfections in our me- 
thods of analysis. 

We will next consider the amount of fixed saline constituents existing in 
the blood of different animals. 



Fibrin in 1000 
parts of blood. 

4.00 
5.00 
3.00 
2.41 
3.70 
4,40 
3.00 
3.62 
3.00 
3.95 
4.60 
3.90 
2.10 
1.93 
3.04 
3.15 
2.42 



Table of the Fixed Saline Matters in 1000 parts of the Blood of different 

Animals. 

Fixed saline matter in 
Name of observer. Name of animal. 1000 parts of blood. 



C. Schmidt. Pond Mussel (Anodonta cygnea) 

Harless and Bibra. Shell Snail [Helix 
Bibra. 
Genth. 



. 0.256 

. 6.12 

Ascidans and Cephalopods . . . 2.63 

Limulus Cyclops ..... 3.327 



Jos. Jones. Stingray [Try gona sabina) . 

Hammerhead Shark (Zygoma malleus) 

" Garfish (Lepis6steus osseus) 

" Salt-water Terrapin (Emys terrapin) . 

Alligator (Alligator Mississippidnsis) . 

" Loggerhead Turtle (Cheldnia carUta) . 

Bullfrog (Rana pipiens) 
Alligator Cooter ( Ckelonura serpentina) 
Yellow-belly Terrapin (Emys serrdta) . 
Chicken Terrapin (Emys reticulata) 
Hog-nose Yiper (Heterodon platyrhinos) 
Black Yiper (Heterodon niger) 
Coach-whip Snake (Psdmmophis fiagelli- 
^ *»' : fdrmis) . ■> . .'I 

Black-Snake (Cdluber constrictor) 
Gopher (Testudo jpolyphemus) 

No. LXIIL— July 1856. 5 



14.70 
8.36 

10.27 

10.74 
8.65 
3.58 
5.78 
4.39 
5.22 
7.79 

13.47 
7.04 



5.57 
8.77 
5.83 



1 Inverte- 
i 

\ brated 
j animals. 

1 Salt- 
j water 
}■ Fishes 
I and 
j Reptiles. 

1 Fresh- 
y water 
j Reptiles. 

i 



Land 
Reptiles. 



G2 



Jones, Investigations on the Solids and Fluids of Animals. [July 



Fixed saline matter in 

Name of observer. Name of animal. 1000 parts of blood. 

Black Buzzard ( Cathartes atrdtus) . 8.33 

Heron [Ardea nycticorax) . . 6.59 | 

Owl (Syrnium nebidosum) . . . 8.06 \ Birds. 

Nasse. Goose . . . . . . . 7.92 

Hen 8.79 J 

Sheep - . 7.76 

Horse 7.85 

Ox 6.95 

Calf . . 7.87 

Goat ........ 7.84 Mam- 
Rabbit 6.28 ' malia. 

Cat . 7.84 

Dog 7.33 

Jos. Jones. Common Cur-Dog .... 6.04 

Common Cur-Dog .... 6.11 

-om this table we learn that the proportion of fixed saline constituents in 
the blood, is remarkably uniform throughout the whole animal kingdom. 
This fact, in connection with others, which will be mentioned hereafter, de- 
monstrates their importance. 

In the invertebrata they exist in largest amount, relatively to that of 
the organic constituents of the blood, than in vertebrate animals. Thus, 
in the blood of the Shell Snail (Helix pomatia), there were 6.12 parts of 
mineral, and only 8.39 parts of organic substances. In the blood of Asci- 
dans and Cephalopods, Bibra found 4.7 parts of organic, and 2.63 parts of 
mineral substances. When we consider the character of the shells of these 
animals, it is not wonderful that the blood should contain so large a propor- 
tion of mineral substances. Schmidt found the albumen of the blood of the 
Pond Mussel (Anodonta cygned) combined with lime. This fact shows that 
these mineral bodies are chemically combined with the organic constituents 
of their bodies. 

Amongst vertebrate animals, we find the largest amount of mineral con- 
stituents in the blood of Fishes and Reptiles inhabiting the salt-water. The 
only exception to this rule was found in the blood of a Loggerhead Turtle 
( Chelonia caretta), which had been kept, for forty-eight hours previous to the 
analysis, in a tub of fresh water. It is probable that an interchange may 
have taken place between the exterior water and the salts held in solution in 
the blood. The blood of the hog-nose viper (Heterodon platyrhinos), yielded 
a larger amount of ash than that of any other animal. This is accounted for 
by the fact that the reptile had been starved for a length of time, and the 
blood was in a concentrated condition. The Alligator is classed amongst the 
salt-water Reptiles, because it had resided in a small salt-water stream, in a 
salt marsh, for about a year. This reptile inhabits, most generally, the 
brackish and fresh-water rivers, lakes, swamps, and rice-fields. 

A knowledge of the constitution of the ash of blood is of great interest 



1856.] Emmet, (Edema Ghttidis from Typhus Fever. 



63 



and importance, not only in a chemical, but also in a physiological point of 
view. 

The researches of C. Schmidt have shown that the fluid contents of 
the blood-corpuscles contain, in addition to peculiar organic matters, a pre- 
ponderance of the phosphates and potash salts ; whilst the liquor sanguinis 
contains the chloride of sodium in large amount, with a little chloride of 
potassium and phosphate of soda. In the blood-cells, the fatty acids and 
globulin are combined both with potash and soda; whilst in the plasma, the 
organic materials are combined only with soda. The researches of Liebig, 
confirmed by those of Schmidt, have shown that the fluid contained in the 
tubules of muscles, is like that of the blood-corpuscles, exceedingly rich in 
the phosphates and potash salts. The phosphates, also, exist in large amount 
in the structure of the brain. From these facts it is probable that one of the 
most important functions of the blood-corpuscles is the separation and elabo- 
ration from the liquor sanguinis, of those organic and inorganic compounds 
which constitute the most important part of the structure of the muscles and 
brain. 

Iron is a peculiar and constant constituent of the coloured corpuscles. Its 
office, in the animal economy, is entirely unknown. The assertions of several 
chemists and physiologists, concerning its power of combining with oxygen, 
and thus aiding in respiration, can at present be considered nothing more than 
a beautiful hypothesis. 

That the fixed saline matters are absolutely necessary, not only for the 
formation of the different structures, but also for the maintenance of life 
itself, was conclusively demonstrated by a series of experiments performed in 
France. It was found that when animals were fed upon grain, from which 
only one element (the phosphate of lime) had been abstracted, they rapidly 
lost their forces, and died in the course of a few weeks. 

We hope to be able to continue this subject in a future number of this 
journal. 



Art. II. — On (Edema Glottidis resulting from Typhus Fever. By Thomas 
Addis Emmet, M. D., late Visiting Physician to the New York State Emi- 
grant Hospital, Ward's Island. 

As a secondary affection of typhus fever, oedema glottidis occurs under 
two distinct conditions. 

The most frequent form met with, is that following laryngitis — the result 
of reactive ulceration of the mucous membrane of the air-passages, in conse- 
quence of typhus deposit. In this condition, general and profuse bronchitis 
is persistent throughout the course of the fever, and is often accompanied by 



64 



Erninet, (Edema Glottidis from Typhus Fever. 



[July 



pneumonia. The infiltration takes place gradually, before convalescence ha3 
been established — usually between the second and third week, and does not 
reach its height for several days. 

The other variety, is a consequent alone of the debilitated condition in 
which the patient is left, after the primary disease has subsided. Convales- 
cence has been slowly taking place, when coincident with some exertion, or 
on suddenly assuming the upright position, asphyxia occurs, and death re- 
sults in a few moments. 

The areolar or cellular tissue is very abundant throughout the glottis, and 
terminates almost abruptly along the under border of the larynx ; at this 
point, when resulting from a debilitated condition (the cellular tissue being 
pervious), the oedema gravitates, and is usually found most extensive. The 
effusion gradually accumulates to a certain point, without producing much or 
any irritation, until, by muscular action, the quantity is suddenly increased, 
and spasmodic closure results. Occasionally, at the upper border of the 
glottis, or on the epiglottis (when depending upon a slight local inflammation), 
the serum accumulates under the mucous membrane in a vesicular or cellular 
form, the vesicle not seeming to communicate freely, the one with another. 
Several of these closing together by accident or gravitation, will form a valve- 
like arrangement, becoming the more perfect with each effort of inspiration. 

When infiltration is the result of the reactive inflammatory action of 
laryngo-typhus, the surface of the mucous membrane is more generally ele- 
vated, smooth, and unyielding — thus equally closing the course of the passage 
throughout. 

Before entering into a consideration of the cases presented, the only point 
of diagnosis which will engage our attention at present, will be that in refer- 
ence to a modified condition of the act of respiration. To a certain extent, 
this can be relied upon as indicative of the locality involved. Bayle and 
many others have stated that, in oedema of the larynx the respiration is alone 
difficult and sonorous in character, while the expiration, on the contrary, is 
free and easy. This statement is partially true, and in such cases only, where 
the oedema exists principally about the epiglottis and superior portion of the 
larynx, resulting from an extension of inflammation from the fauces, or in 
consequence of the inhalation of steam, irritating substances &c. Thus, as a 
result of situation, and the prominent or vesicular form of the oedema, with 
each act of inspiration (as we have already seen), a valve is formed, closing 
from above downwards. When the infiltration is more general, and caused 
by acute laryngitis, syphilitic ulcerations, tubercular or typhus deposit, it 
may extend or not to the epiglottis and neighbourhood, while a more equable 
diminution in caliber is produced. Thus both the inspiration and expiration 
will be very nearly equally affected. In the asthenic form, the accumulation 
having gravitated (which it will always do when existing independently of an 
inflammatory obstruction), it hangs free, as a sac into the trachea. While 
this condition also materially lessens the area, it offers comparatively but little 



1856.] 



Emmet, (Edema Glottidis from Typhus Fever. 



65 



obstruction to inspiration; the expiration, on the contrary, is, I believe, in 
every case unnaturally prolonged, and difficult in proportion to the extent of 
the accumulation. This seems to be in consequence of the upward pressure 
from behind, in the outward passage of the air — as closure of a semilunar 
valve is produced by regurgitation. In Case V., cited, the sac in its free diame^ 
ter was quite sufficient to have produced complete closure in this manner. 
As the difficulty increases, it is easy to conceive that, beyond a certain point, 
the sac would cease to be movable as a valve, and both acts of respiration (if 
complete asphyxia has not already supervened) would be equally affected, 
while the application of the stethoscope, in a case of doubt, would determine 
with much certainty the exact point involved. 

Case I. A male, aged 18, a native of Ireland, and ten days from ship- 
board, was admitted to the fever ward of the hospital, under my charge, 
Nov. 20, from the city. His general appearance was phthisical, with light 
hair, blue eyes, and of a spare habit. The previous health had been good; 
he never had contracted syphilis, and his parents were healthy. After a loss 
of appetite, and general lassitude for several days, he was seized on the 17th 
inst. with a chill, followed by headache and fever, and on the second day with 
cough and pain in the chest. He was admitted, on the third day of his in- 
disposition, with the typhus eruption out, and the fever well marked in every 
respect. A profuse double bronchitis, with pneumonia, existed — more exten- 
sive on the left side. Nothing of note occurred during the actual course of 
the disease, which was rather of a more severe type than usual. The pneu- 
monia did not advance beyond the first stage, and disappeared in a few days; 
while the bronchitis was never entirely absent, often rapidly increased in 
severity, and would sometimes as suddenly subside in intensity on the same 
day. During the night of the fifteenth day of the disease, and on the 2d inst., 
a marked remission took place. In the morning, the pulse had lowered in 
frequency, and the fever lessened, while the tongue became moist at the edges. 
The expression of the face, as well as the general appearance, was indicative 
of convalescence about being established. The quantity of brandy (of which 
he had been taking some ten ounces a day) was now decreased. During 
twenty-four hours the condition remained nearly stationary. About bedtime 
of the evening of the 3d, he complained of a sore throat, followed by some 
difficulty in swallowing. During the night, the inspiration was first impeded, 
afterwards the expiration became principally so, while dyspnoea, with slight 
hoarseness came on, accompanied by tenderness of the larynx on pressure. The 
fauces were found injected, and the epiglottis felt distinctly tumid, elevated and 
smooth, while the voice sank to a whisper, as the parts lost their elasticity. 
He assumed the upright position from choice, and became restless. The lower 
extremities were being constantly flexed, and extended in turn ; the hands 
were often applied to the region of the pomum Adami, and apparently with- 
out any definite object for doing so. On being questioned, he seemed too 
much occupied with his condition to give a satisfactory answer. The skin 
was hot and dry, becoming afterwards cold and clammy ; the neck and face 
suffused and puffy in appearance. The eyes became prominent and injected, 
and the nostrils tremulous. The pulse at first increased rapidly in frequency, 
but afterwards became weak, small, compressible and irregular, until it inter- 
mitted and ceased. The epiglottis was freely scarified ; a blister applied to 
the upper part of the sternum, with dry cups to the nape of the neck, and 



66 



E miner, (Edema Glottidis from Typhus Fever. 



[July 



along the root of the lungs, on each side of the vertebral column. Calomel, 
quinia, and Dover's powder, in combination, were taken, and repeated every 
two hours. On the morning following, his condition was worse in every re- 
spect, with the expiration much prolonged, and with a croupy sound. A solu- 
tion of argent, nitras (5 ss_ f5j) was applied freely to the fauces and epiglottis, 
which was followed by some temporary relief. During the day, the calomel 
was stopped, but I continued the use of the quinia and Dover's powder, and 
ordered wine whey. The operation of tracheotomy was proposed, which he 
refused — wishing (in his own words) to die in preference to having his throat 
cut. Through the night he sank rapidly. Suffocation was inevitable on the 
morning of the 5th inst. ; the lungs were being blocked up from venous accu- 
mulation; the brain was already suffering in consequence, and the patient 
sinking into an insensible condition. The trachea was opened about 11 o'clock 
A. M., with the full conviction that a different issue might have resulted, could 
the operation have been performed earlier. Before its completion, life appa- 
rently had ceased. The lungs were inflated, and the ribs depressed in turn ; 
soon the heart's action was again perceptible, and was followed by reaction 
in the course of fifteen or twenty minutes. With the return of consciousness, 
he seemed much relieved, and in half an hour afterwards sank into a sound 
slumber, for the first time during thirty-six hours. He took a moderate quantity 
of stimulants and beef-tea during the day, with large doses of the muriated 
tinct. of iron. The pulse sank to 90 per minute, after having been, previous 
to the operation, too rapid to count. He breathed regularly through the tube, 
yet but little change took place in the dtilness, which was extensive at the 
posterior and inferior portion of the lungs, with quite an accumulation of 
mucus in the bronchial tubes. He suddenly awoke about 7 o'clock P. 31.. 
with a return in the difficulty of breathiDg ; no obstruction existed in the 
tube; the lungs were found to be becoming engorged; the bronchi filled; 
while the dulness on percussion had sensibly increased over nearly the whole 
chest, from below upwards. The temperature of the trunk augmented, that of 
the extremities diminished, while the features became pinched in appearance. 
The pulse was soon countless from its frequency, wanting in volume, and 
afterwards irregular and intermitting. Stimulants, frictions, counter irri ra- 
tion, and a stimulating enema, together with dry cups, were resorted to with- 
out relief. He sank slowly into a profound coma, and died eighteen hours 
after the operation, on the fourth day of the attack, and the nineteenth of 
the fever. 

Post-mortem examination seven hours after death. — General oedema, and 
thickening of the submucous structure of the glottis, was found terminating 
along the under border of the lower vocal ligament. Some infiltration of the 
epiglottis existed, but its surface was corrugated. A large, deep ulcer, with 
blackened edges, existed in the posterior part of the ventricle on each side, 
together with a few superficial ones scattered here and there in the neighbour- 
hood. The lining membrane of the trachea above the bifurcation was par- 
tially injected, below this point it was very much so; several, small and empty 
ulcers were found, and the bronchi filled with a thin, frothy mucus. Both 
lungs were engorged with venous blood, which flowed freely with each incision 
made. Not a trace of tubercle existed. ' The heart was softened, and of a 
dark colour, from venous congestion of its capillaries; the right side with its 
vessels was greatly distended, while the left was nearly empty. The spleen 
was enlarged and friable, the liver congested, and all the veins of the portal 
system were distended, in consequence of the retarded circulation. The 
larger vessels on the surface of the brain were in the same condition, while 



1856.] 



Emmet, (Edema Glottidis from Typhus Fever. 



67 



quite an extensive effusion of serum had taken place under the investing mem- 
branes. Some opacity and thickening of the dura mater was found principally 
along the course of the longitudinal sinus on both sides, with a few points of 
effused fibrin scattered over the surface. A cross section into its substance 
showed the congestion to be general; on extending it into the lateral ventricles, 
they were found filled with serum. The substance of the brain was in con- 
sistence somewhat softer than natural, although not sufficiently so to be re- 
garded as a pathological condition. About two ounces of fluid were contained 
in the spinal canal. The blood of the general system was in a fluid state, and 
presented the " claret sediment" appearance, often found in typhus fever. 
Nothing further of interest was noticed, and especially no ulcerations of the 
glands of Peyer existed. 

Case II. James Hogan, 30 years of age, was admitted on the 2d of 
January. The case was early marked by great deafness and stupor, from 
which condition he could at all times be partially roused; no eruption ap- 
peared. Bronchitis came on after the first week, and was persistent; it was 
accompanied by the crepitant rhonchus of pneumonia, which disappeared 
entirely in a few days. On the 18th day of the disease, symptoms of laryn- 
gitis were noticed; the fever remitted somewhat on the 21st day, but the 
local difficulty increased. About 9 o'clock A. M. of the 23d day it was evi- 
dent (after the occurrence of the symptoms detailed in the preceding case) 
that the general system was rapidly failing from an inadequate supply of oxy- 
gen, and the consequent accumulation of carbonic acid. As a last resort, the 
trachea was opened, which was followed by general prostration. By means 
of artificial respiration, partial reaction was established, with much relief. 
During eighteen hours the patient's condition was comfortable, but he became 
conscious that only temporary relief had been obtained. The circulation was 
very incomplete, as a large portion of the lungs remained clogged up. In 
twenty-four hours the bronchitis became general, the lungs slowly congested, 
and the bronchi filled. He sank from a gradual stupor into a comatose con- 
dition, and died forty-eight hours after the operation, on the twenty-sixth day 
of the fever, and on the eighth day of the laryngitis. 

The post-mortem appearances were characteristic. A deep empty ulcer, 
with dark edges, was found occupying a similar position in the ventricle of 
the larynx, but somewhat smaller than that of the preceding case. The 
oedema and thickeuing of the submucous structure was general throughout 
the glottis. The mucous membrane of the trachea and bronchi was much 
congested, while the superficial ulcerations in the latter were more numerous. 
The condition of the brain, heart, lungs, and intestines, was in every respect 
similar. It is worthy of remark, that of two or three other cases occurring 
in the service of the gentlemen connected with the institution, the same un- 
happy result followed the operation. 

It is a fortunate circumstance, that, in comparison, the occurrence of laryn- 
gitis in this form is a rare complication in typhus fever, and still more so 
that it does not invariably produce, in consequence, a sufficient oedema of the 
glottis to require the trachea to be opened for its relief. When laryngo- 
typhus is so severe in its effects as to endanger life, the operation of either 
tracheotomy or laryngotomy is of doubtful efficacy, while we have no better 
means of relief to offer. The only hope for success in this disease, as in all 
others where the operation is resorted to, lies in acting without delay, as soon 



68 



Emmet, (Edema Glottidis from Typhus Fever. 



[July 



as the first indication of a stasis in the circulation through the lungs is de- 
tected. The following condition results : the vis d tergo continues, while the 
venous blood thus sent to the lungs, will not pass readily on to the left side 
of the heart, until the proper functional changes have been fully effected. 
Stagnation gradually takes place in the minute radicles of the pulmonary 
veins (which probably require to be stimulated to action by the presence of 
oxygen), until a large portion of the lungs becomes completely destroyed in 
function. The result is, that nothing is gained by an operation at so late a 
period, from the fact that the obstruction will remain, and too small a portion 
is left in its integrity for the purposes of maintaining life. Even on the other 
hand, if the condition has not advanced so far, it is greatly to be feared that 
the irritation consequent upon the operation will be sufficient (if it has ceased), 
to re-establish the bronchitis, which has already subsided but a short time 
previously. The reactive inflammatory action of the larynx rapidly descends, 
the bronchitis becomes profuse, and results invariably in an intense con- 
gestion of the lungs; general infiltration takes place; the bronchi soon be- 
come filled with a fluid accumulation, which the patient is now unable to 
remove, and death results from suffocation. The cause, then, of oedema glot- 
tidis in laryngo-typhus, is to be regarded as resulting from a local inflamma- 
tory obstruction, and is more pathognomonic of typhus fever than that of the 
other variety, which is considered (as we have seen) an effect alone of a dimi- 
nution of the vital forces, and independent directly of the original disease. 
We now pass to a consideration of this condition. 

Case III. William Daly, aged 20; eleven days from ship; was admitted 
from the city on the 12th of March, with the eruption just fading. The 
fever was of a grave type, but ran its course uncomplicated. The case slowly 
convalesced for several days, when, on the nineteenth of the disease, between 
5 and 6 o'clock P. M., suffocation came on in consequence of suddenly sitting 
up in bed, for the purpose of receiving his food. I obtained the assistance of 
my colleague, Prof. Carnochan, and the trachea was opened some five minutes 
after the occurrence of the accident. But, before the operation was completed, 
the patient was pulseless and insensible; all attempts at respiration had 
ceased, while the heart's action was no longer perceptible. In a few minutes 
after artificial respiration had been commenced, the livid appearance about 
the neck and face began to disappear, and soon a feeble action of the heart 
was again detected. At the end of some ten minutes, complete consciousness 
and gradual reaction were established. From this time, the necessity for in- 
flating the lungs artificially ceased ; but, for a period of five hours and several 
minutes after the operation, coincident with each expiration, I depressed the 
ribs. The muscular or contractile power of the respiratory apparatus appeared 
completely paralyzed. After depressing the ribs, the air, of course, readily 
passed in to fill the partial vacuum thus produced; but, when I ceased doing 
so (as I did several times from fatigue), suffocation was almost immediately 
produced, the face and neck became livid, and the patient soon insensible. 
So dependent did he feel on me for this assistance, and so fearful' was he I 
might leave him, that my wrists were severely bruised in consequence of his 
grasp during nearly the whole time. At midnight, all danger was removed; 
and ten grains of Dover's powder, with two of quinia, being administered, he 



1856.] Emmet, (Edema Glottidis from Typhus Fever. 



69 



slept well during the night, and no further difficulty arose. The tube was 
removed on the eighth day, and the wound soon healed, but it was not until 
the one hundred and third day after admission that he had recovered his 
strength sufficiently to be discharged. 

Case IV. Thomas Goffrey, aged 40, was admitted on the 4th of Feb- 
ruary. The course of the fever differed but little from that of the preceding 
case, with the exception that no eruption appeared. The convalescence was 
slow, with some oedema of the feet, while he was up and about the ward for 
several days. On the 26th inst. he called my attention to his throat, which 
was sore, and at the same time I noticed some hoarseness in the tone of voice. 
As he arose from the bed for the purpose of examination, he became suffo- 
cated, and in a short time insensible. Dr. G-eorge Ford, my senior, being 
present, opened the trachea; this was followed, after depressing the ribs seve- 
ral times, by almost immediate relief. The tube was removed on the ninth 
day, and the case discharged on the fifteenth after the operation, and on the 
thirty-fifth day after admission. 

Case V. Shortly after the discharge of the above case, a man under my 
charge, as house physician in the service of Dr. Henry Gr. Cox, became similarly 
affected on the twenty-eighth day after admission. He was 31 years of age, 
and had almost entirely recovered his strength, after a serious attack. As in 
the other cases, without any premonitory difficulty in breathing, the accident 
was preceded by a sudden change in position. I was absent from the ward 
at the time; thus an unfortunate delay occurred before the trachea could be 
opened, and although life was not quite extinct, no reaction followed the 
attempt at resuscitation. I was informed afterwards by the nurse, that he 
had mentioned, the day previous, having a tickling or disagreeable sensation 
in the throat, which had been attributed to taking cold. At the post-mortem 
examination, some slight oedema of the superior portion of the glottis existed. 
On the left side, along the under border of the lower vocal cord, the oedema 
had accumulated in a pendulous sac, nearly closing the opening below. The 
mucous membrane of the respiratory organs was not injected, and no 
evidence of inflammatory action existed anywhere. The lungs were perfectly 
sound, and only presented the usual appearance resulting from asphyxia. 
The other organs were also in a healthy condition, while the venous congestion 
was not so extensive, and principally confined to the lungs and larger vessels 
of the brain. The left side of the heart was nearly empty; the right side, 
with its cavities, distended; and, in fact, the organ presented the general 
condition already described. It is not unreasonable to suppose a happy re- 
sult would have followed an immediate operation, could it have been possible. 

Case VI. came under my charge while a house physician in the service of 
my late friend and colleague Dr. Macneven. A female, aged twenty, was 
admitted with fever on the 14th of April; on the 10th of May following, 
after convalescence had been established some eight days, suffocation sud- 
denly occurred. Tracheotomy was promptly performed, and followed by a 
complete recovery. The tube was removed on the sixth day, and the case 
discharged on the eleventh after the operation, having been thirty-seven days 
under treatment. 

Case YII. occurred also in a female, aged 23, who was admitted on the 
10th of December. The fever was uncomplicated, and abated on the twelfth 
day. The convalescence (with oedema of the feet), was tedious up to the 5th 



70 



Emmet; (Edema Gloltidis from Typhus Fever. 



[July 



of January, when symptoms of cederna glottidis were manifested. Complete 
asphyxia did not at any time take place, but a certain amount of difficulty in 
expiration existed during some eight days; it was sudden, spasmodic, and 
increased by muscular exertion — sometimes even while speaking. The appli- 
cation of the stethoscope in the neighbourhood of the thyro-cricoid space, indi- 
cated beyond doubt the existence of a constriction at this point, which gra- 
dually disappeared, and at the time of discharge, the sounds were of a normal 
character. With the exception of an occasional occurrence of dyspnoea and 
hoarseness, all the other symptoms were negative in character. On examina- 
tion, neither the fauces nor epiglottis presented any change from a healthy 
condition. There was no interruption to the circulation, and consequently 
no change was produced in the lungs. The pulse increased in frequency 
as the dyspnoea was augmented, but otherwise, was alone indicative of a debili- 
tated system. Preparations for operating were early made, but happily the 
exigencies of the case did not require it. The treatment consisted in main- 
taining perfect rest in the horizontal position so long as danger existed, extra 
diet, and a moderate quantity of stimulants. Quinia and iron in combination, 
were freely administered, with Dover's powder at night when required. A 
number of dry cups were repeatedly applied on each side of the vertebral 
column, along the root of the lungs; while an application of the tinct. of 
iodine was made externally over the region of the larynx, and the tempera- 
ture of the extremities regulated by artificial means. The discharge took 
place on the 20th of January, the case having been forty-one days under 
treatment. 

Case VIII. A male, aged 47, was admitted in March, having been five 
days indisposed. The typhus eruption appeared the day after admission, and 
was present until about the twelfth day. Slight bronchitis came on during 
the first week and soon subsided. The case was of a very low type, so much 
so that a large bed-sore formed on the right buttock between the second and 
third week, and the cornea sloughed on the nineteenth day. Between the 
third and fourth week the fever abated, leaving the case perfectly prostrated; 
from this condition, together with the irritation of the bed-sore, no reaction 
followed, and death occurred forty three days after admission. Post-mortem 
examination : emaciation was extreme ; nothing worthy of note was detected, 
with the exception of some infiltration of serum in the inferior portion of the 
larynx, while there was no appearance of inflammation whatever. I regarded 
the quantity at the time, as being too small to have materially influenced the 
termination ; since then, with more experience, I have satisfied myself that a 
very slight obstruction at this point is sufficient to influence and gradually lower 
the tone of the general system, without giving any evidence of its existence 
during life. I was somewhat surprised to find that no tuberculous infiltration 
had taken place in the lungs, as his general appearance, some days previous to 
death, had led me to suspect such would be the case. 

Case IX. Also a male, aged 29, was admitted in January, on the second 
day of the attack, with the eruption just out. It was a malignant case, but 
uncomplicated ; for several days (between the second and third week) sixteen 
ounces of brandy were administered during the twenty-four hours. On the 
twentieth day an abscess was opened, which had formed under the scapula, 
and from which some five ounces of pus were evacuated. At what ti me the 
typhous influence subsided, it was impossible to note, as it ran into a low 
irritative fever in consequence of the great discharge from the abscess; this 



1856.] Emmet, (Edema Ghttidis from Typhus Fever. 



71 



condition lasted until death, which occurred on the 39th day after admission. 
The oedema was similarly situated in the larynx, but more extensive than that 
in the preceding case, yet gave no indication of its existence during life. 

I am convinced, when reaction does not readily take place, that oedema of 
the glottis exists after many diseases, as a consequence of the extremely 
debilitated condition resulting, and may be the immediate cause of death 
oftener than is suspected. Since my attention has been directed to this subject 
I have met with this condition in two other cases; the one after death from 
chronic diarrhoea, and the other after a long protracted case of Chagres fever, 
both being without tubercular deposit. As there is so little indicated which 
cannot, in these cases, be accounted for, as a result of the disorder of the general 
system, the condition may be easily overlooked even after death. We must 
suppose, in consequence of its gradual accumulation, the system becomes to a 
certain extent accustomed, and adapts the want to the supply, until, eventually? 
the vitality of each organ becomes so much lowered that death gradually takes 
place. This explanation is identical with that which occurs in many cases of 
phthisis, where, after death, so small a portion of the lungs is found unaffected 
by disease, that it is a matter of surprise how life, often, under such circum- 
stances, could possibly have been maintained so long. It will be a matter of 
interest for future observation, to examine the condition of the larynx in those 
cases of sudden death after typhus, which sometimes occur on placing a patient 
in the upright position ; under such circumstances it is the custom to attribute 
the cause of death to anaemia, or some disturbance of the circulation in the 
brain ; an explanation which is convenient only as a cover to our ignorance on 
this point. 

After a review of the cases presented, it is evident that a more favourable 
issue is likely to follow the operation of tracheotomy, or laryngotomy, when 
employed for the relief of the asphyxia following simple oedema, than that 
resulting from the local cause. In the table exhibited, it will be observed, 
that, in every fatal case of laryngo-typhus, bronchitis existed; and, further- 
more, that it invariably recurred after operating, as soon as reaction was 
established. The result was different where convalescence had already taken 
place, as the reactive inflammatory tendency had subsided, while there seems 
but little likelihood of its being again established from this cause, even if 
bronchitis had previously existed. 

' In reference to a choice of locality for operating (in the latter condition 
especially, where the least delay is of such vital importance), the opening 
should be made through the thyro-cricoid space. From experience, I am 
satisfied nothing is to be gained by tracheotomy; the other operation is more 
simple and as effective, while, at the same time, being also below the termi- 
nating point of the oedema, the risk of establishing an inflammatory action is 
not thus materially increased. But in either variety, if tracheotomy is decided 
upon, after the first incision made through the integument (as the veins are 
always enormously distended), the instrument should be laid aside. The 



72 



Emmet, (Edema Glottidis from Typhus Fever. 



[July 



subjacent structure can be rapidly separated by means of the thumb-nail or 
handle of the scalpel • if this is not done, even with the greatest care, the 
hemorrhage will often be fearful, and so far delay the opening that death will 
result. After a removal of a portion of the trachea has been effected, it is 
advisable at first not to introduce the tube, as the mucous membrane is in an 
exceedingly irritable condition j unfortunately this exists principally in the 
posterior portion of the trachea, and where the muscular structure is most 
abundant. At this point, with the least displacement of the instrument, and 
with each act of swallowing the saliva, a spasmodic condition is being constantly 
excited, which is doubtless transmitted to the minutest subdivision of the 
bronchial tubes, thus diminishing the extent of surface available for respiration. 
This irritability usually passes off after reaction has been fully established, 
provided bronchitis has not occurred ; the tube may be then used or not, as 
maybe deemed advisable. It is decidedly safer to rely upon some mechanical 
contrivance to keep the lips of the wound apart, because the largest tube which 
can be introduced cannot equal the natural capacity of the trachea; the mucus, 
which appears in large quantities at the opening, can be more easily removed, 
while a larger quantity of air seems able to pass in a given time through a 
simple incision, with the lips well separated, than through a tube which the 
cut will receive ; this is naturally inferred as the number of inspirations 
decrease within a short time after the removal of the tube. 

After the operation, artificial respiration, a stimulating enema, frictions, 
with the application of artificial heat to the extremities and other means, must 
be persevered in, until no possible hope remains of resuscitation. The patient 
must not be left until the circulation has been completely re-established, and 
the extremities become of a comfortable temperature. This is obviously 
necessary, as we have seen already, the respiratory power does not completely 
recover its tone, sometimes for many hours after the operation. Occasionally, 
within the first twelve hours, this difficulty will occur again, even after the 
function has been carried on for some time unaided ; if, under such circum- 
stances, assistance be not at hand immediately, to depress the ribs for the 
moment until the danger is again removed, the result will be fatal. As the 
air passes directly into the lungs almost entirely unchanged, the temperature 
of the room, must be regulated with care and kept as nearly as possible of an 
equable degree, as either bronchitis or congestion of the lungs will be likely 
to result in consequence of any sudden change. Perfect rest must be main- 
tained in the horizontal position, until all irritability of the system has ceased. 
The circumstances of the case can alone indicate when the tube, if used, can 
be removed and the wound closed with safety. In the mean time it is obvious, 
that every means must be employed for the purpose of building up and 
improving the general system, as rapidly as possible. 

During a service of five years in the institution, one thousand nine hundred 
and thirty-one cases of typhus fever came under my charge. Of so large a 
number, only twenty-three were of the laryngo-typhus form, and seven were 



1856.] Emmet, (Edema Glottidis from Typhus Fever. 73 



cases of simple oedema glottidis, from debility without inflammation, and with 
the following result : — 



Typhus fever and oedema glottidis, -with the 
complications in order as they occurred. 


TOTAL NUMBER. 


DUMBER AND 
RESULT OF 
OPERATION. 


AVERAGE NUMBER 
OF DATS UNDER 
TREATMENT. 


Cured. 


Died. 


Treated. 


Cured. 


Died. 


Cured. 


Died. 


Feb. typhus, broncho-pneumonia, 
















laryngitis, et oedema glottidis 


7 


6 


13 






57 


OI 1 

-J- tT 


Feb. typhus, broncho-pneumonia, 
















laryngitis, glosso-pharyngitis, et 
















oedema glottidis .... 




1 


1 








43 j 


Feb. typhus, broncho-laryngitis, et 
















oedema glottidis .... 


4 


1 


5 








19 


Feb. typhus, diarrhoea, laryngitis, 














pharyngitis, et oedema glottidis . 


i 
i 




i 
i 






qc 
vo 




Feb. typhus, laryngo-pharyngitis, 


hi *ft 














parotitis, et oedema glottidis 


2 




2 






28 




Feb. typhus, laryngo-tonsillitis, pa- 
rotitis, et oedema glottidis . 


- 














1 




1 






122 


... 


Total result from the local cause . 


15 


8 


23 




2 


54 


24 


Total result from the general condi- 
















tion . . 


4 


1 


5 


2 


1 


53* 


28 


Total result from the general condi- 
















tion (discovered after death) 




2 


2 






... 


41 


Total 


19 


11 


30 


2 


3 


54 


25 iV 



The average age of the whole number (30) was 24 years — the ages rang- 
ing from 12 to 47 years; of 20 cases, the average duration of disease previous 
to admission, was exactly five days and twelve hours — the time ranging from 
2 to 10 days. The complications occurred in different months as follows : — 



Jan. Feh. March. April. K"ov. Dec. Total. 
Cases .... 7 4 8 4 1 6 30 

The word angina, or quinsy, was used by the early writers to express any 
obstruction occurring in respiration or deglutition, seated above the lungs or 
stomach. Hippocrates, Celsus, and Aretgeus treat of two forms of obstruction — 
the one situated within the larynx or upper portion of the trachea, and only 
recognized by producing sudden suffocation ; the other in the fauces, or about 
the epiglottis, and visible. Aretgeus regarded the former variety as being so 
suddenly fatal in character, that he compared its effects to that produced by 
carbonic acid; or, in other words, to " vapours inhaled from pits or caverns," 
and that death resulted before any means could be employed for its relief. 

Boerhaave, in Aphorism 784, states: " Of this disease there are observed 
two kinds. The first appears without any manifest sign of tumour or swell- 
ing, either external or internal ; but the other kind is constantly found with 
some tumour in one part or other," &c. Again, in the next aphorism : "The 
former of these happens mostly in the end of lingering diseases, especially 
after profuse and often repeated evacuations. It is attended with a paleness, 



74 



Emmet, (Edema Glottidis from Typhus Fever. 



[July 



dryness, and shrinking of the fauces at the same time, and therefore the 
nerves and muscles are commonly paralytic in this case; it is almost con- 
stantly a sign of death approaching, being very seldom curable, and then only 
by such remedies as fill the empty vessels with good juices, and which warm 
and corroborate at the same time.' 7 Aphorism 786: "This first kind of the 
disorder sometimes arises suddenly without manifest signs of any disease pre- 
ceding; it hardly admits of a cure; and it almost constantly, after death, 
demonstrates a suppuration in the lungs." Van Swieten, in his commentaries 
on this aphorism, also states : " But observations teach us that, sometimes, 
even in healthy people without any signs of diseases preceding, the deglutition 
or respiration, or both, are suddenly impeded, and death follows soon after, 
though there is no tumour in the fauces or external parts." Again : " But, 
in the mean time, it is certain that this very rarely happens, since we do not 
here treat of an inflammation suddenly arising about the upper parts of the 
larynx, which, indeed, very speedily kills by suffocating the patient, but may 
be known and distinguished by the acute pain and other signs preceding or 
attending the disease." According to the same author, Schenckins relates a 
case of " suffocating catarrh," which occurred in a man who had no disease 
except a " weariness or lassitude," was seized suddenly and suffocated before 
any assistance could be rendered. He also states such cases are rare, and 
that the lungs after death are found " suppurated." The word catarrh does 
not imply that an inflammatory action existed ; we have just seen that Yan 
Swieten states distinctly in this form — " we do not here treat of an inflamma- 
tion," &c, while in this connection we find the following : "Many authors 
have called the like disorder a suffocating catarrh, because they constantly 
believe it to arise from a sudden distillation of dissolved humours upon the 
lungs and fauces. For when they saw in the disorder called a coryza, that 
there often happens such a sudden and copious flux of a sharp serum through 
the nose ; and that the Schneiderian membrane suddenly swelled so as to im- 
pede all the passage of the air through the nostrils, which are naturally so 
large, they with good reason believed that something of the like nature might 
happen in the membranes investing the larynx or windpipe, from whence 
must follow the most sudden suffocation and death." Sydenham also relates 
a case which suddenly occurred after " a continued intermittent fever;" he 
regards the disease as being rare and very fatal, while the lungs are found 
'•'engorged after death." Boerhaave treats particularly of "the watery cede- 
matous or thin catarrhous quinsy," and non inflammatory (in Aphorism 791), 
which is caused, as he states, by " a too weak circulation of humours." Yan 
Swieten describes the watery quinsy as being found "in the larynx or wind- 
pipe, by which free respiration is disturbed, and that it occurs in weak, pale, 
and leucophlegmatic patients, who have almost their whole body swelled with 
a cold sluggish tumour." He recommends, as a treatment to strengthen 
their solid parts, by the salutary use of chalybeates, more especially dissolved 
in vegetable acids, to increase the languid motion of the humours. 



1856.] Emmetj (Edema Ghttidis from Typhus Fever. 



75 



We now pass to a consideration of the condition of the larynx where, from 
inflammation, the diameter is more nearly equally diminished throughout, and 
extending from the body towards either extremity of the organ, or to both. 
(Boerhaave, Aphorism 801) : 11 If the windpipe only is inflamed in the mus- 
cular membrane which lines it internally without injuring other parts, then 
there follows a tumour or swelling therein, with heat, pain, and an acute, 
ardent fever, but without any signs externally; the voice becomes shrill, 
squeaking, and wheezing or whispering; inspiration is attended with an acute 
pain ; the respiration is small, frequent, performed with great labour and with 
an erect or raised posture of body ; hence the circulation of the blood becomes 
difficult through the lungs, the pulse waves or trembles very swiftly, and in a 
surprising manner; great anguish and oppression attend, and death soon fol- 
lows;" "the nearer the disorder is seated to the glottis and epiglottis, so much 
the more fatal is it." Van Swieten, in describing the same condition, remarks : 
" Thence this inflamed membrane is stretched, and thus an acute pain is pro- 
duced in the act of inspiration. But expiration is likewise impeded, as the 
air cannot pass from the lungs but in a less quantity through the windpipe, 
now straitened by an inflammatory tumour, whence it is obliged to pass 
with a greater celerity ;" and again, " the air cannot conveniently pass into, 
nor out from the lungs, as it used to do in health." Hippocrates observed this 
form of the disease, and states that death from suffocation takes place on the 
same day, or on the second or third, or fourth. 

Of the third variety, Hippocrates, Aretasus and others, observed that when 
the inflammation is situated about the epiglottis and fauces, the difficulty is in 
the inspiration. Thus, Aretaaus states: "But they draw their breath very 
short, until they are suffocated, the passage into the lungs being intercepted." 
Death, according to Hippocrates, occurred in these cases on the fifth, seventh, 
or ninth day. 

Morgagni, at a modern date, was the first to enter into detail in describ- 
ing this disease. Bichat followed, locating the affection in the superior 
portion of the larynx, and described it as a peculiar species of serous en- 
gorgement found in no other portion of the body, producing death by suffo- 
cation ; but, in many respects he was vague and indefinite. Bayle, early in 
the present century, with more accuracy detailed the disease and circum- 
stances under which it was found. He distinguished two forms in which the 
oedema occurred — one idiopathic, and arising spontaneously; the other 
secondary, or subordinate to some local laryngeal affection. He noted also its 
occurrence in the non-inflammatory form during convalescence from typhoid 
fever, and that its existence, up to the moment of suffocation, was unsuspected. 
M. Thuilier, a few years afterwards, advocated Bayle's views, and regarded 
the non-inflammatory form as a distinct condition. Bouillaud, in 1825, denied 
the occurrence of cedema glottidis from any other cause than that resulting 
from local inflammation. Cruveilhier's views agree with those of Bouillaud, 
while he describes the disease as a submucous laryngitis. Legroux, Trousseau 



76 Emmet, (Edema Glottidis from Typhus Fever. [July 

and Belloc, Bricheteau, Vidal (de Cassis), and in fact nearly every writer on 
the subject, seems only to have met with the inflammatory form. Ryland 
defines oedema glottidis as a variety of laryngitis, in which the submucous 
tissue of the superior part of the larynx becomes oedematous by the inflamma- 
tory process, whilst the external surface of the mucous membrane is found 
free from any signs indicative of the existence of inflammation. Two cases 
are given as types of this condition — in one an ulcer existed, with vascular 
edges; in the other the mucous membrane was congested, with an infiltration 
of pus in the sub-cellular tissue. In both oedema existed at the superior 
portion of the larynx, resulting from the inflammatory obstruction below; 
indeed, they may well have been classed under the head of laryngitis, from 
which cases they differed but in a degree. M. De Lesiauve, in a memoir on 
oedema glottidis (reviewed in Banking's Abstract, 1845, art. 4), subscribes 
to the opinion advanced by Bayle, and regards one form of the disease as 
idiopathic and independent of inflammatory action. Dr. Thomas Watson 
(Lectures on the Principles and Practice of Physic), states : " A distinction 
has been made between laryngitis and oedema of the glottis, and it is a just 
and real distinction. (Edema of the loose areolar tissue subjoined to the 
mucous membrane of the glottis, is indeed one common consequence of inflam- 
mation of that membrane, but it may occur independent of inflammation." 

Dr. Horace Greene, of New York (Polypi of the Larynx and (Edema Glot- 
tidis), remarks, in treating of this affection : " When the disease occurs 
independent of any other local affection, it is termed idiopathic ; and second- 
ary, when it follows diseased action of the larynx, or of any of its neigh- 
bouring tissues. Not unfrequently the affection arises during convalescence 
from typhus and other forms of fever. It originates, also, from inflammation 
and from ulcerations of the lining membrane of the larynx." M. Valleix 
(Guide du Medecin Praticien) enumerates, as a cause of oedema glottidis, 
typhoid fever, and admits that it occurs in persons debilitated by acute or 
chronic diseases ; while he regards this circumstance as being " the only one 
that observation has placed completely beyond doubt." Again, we find in 
contradiction, " a last question which regards the nature of this disease, is to 
know if oedema of the glottis can develop itself without previous inflamma- 
tion ; in other words, if there is an essential oedema of the glottis." And : 
" It is at least doubtful whether there exists an oedema glottidis purely pas- 
sive, for the facts cited to prove this occurrence are very few and incomplete." 
M. Valleix, in explanation as to the cause which misleads,, maintains "that 
traces of slight inflammation in the laryngeal mucous membrane, sufficient 
under certain circumstances to produce oedema, may disappear after death." 
What these circumstances may be, by which traces of inflammation, with the 
consequent oedema are removed, it is not easy to conceive. A moment's re- 
flection on the mode of death and over-distended state of the venous system, 
would be conclusive that this is impossible. It is theoretical, for the arterial 
capillaries are never found empty, although the character of the blood may 



1856.] Emmet, (Edema Glottidis from Typhus Fever. 



77 



have been changed, the difficulty occurs at this point early, and is accumu- 
lative ; we would, therefore, fiad, if arterial congestion had existed previous 
to the first difficulty in respiration, the condition would be actually increased. 
The same reasoning applies to the examples given by MM. Trousseau and Bel- 
loc, in the disappearance, after death, of redness in parts previously affected 
by erysipelas, the exanthematous eruptions, &c. These gentlemen also cite 
cases in which the white colour from infiltration of pus, with oedema at the 
superior portion of the larynx, may deceive. There can be no differing in 
opinion with them, as to this circumstance being proof positive of the pre- 
vious existence of inflammation somewhere, even in the absence of all conges- 
tion of the parts. 

Such cases are not in question, as there is no interruption of the general 
circulation previous to death — while the locality of the oedema is demonstra- 
tive of the cause. If it takes place in consequence of debility, it will gravi- 
tate to the most dependent part ; on the contrary, when inflammation has 
existed by adhesion, the permeability of the areolar tissue is destroyed, and 
the infiltration, which is uniform, cannot be removed by puncture at any one 
point. As MM. Trousseau and Belloc have truly stated, after inflammation 
the infiltration below the oedema is found to be pus or sero-purulent in cha- 
racter; such is not the case in simple oedema. In the cases of oedema which 
have come under my observation, the areolar tissue became soon greatly emptied 
and corrugated in consequence of the incision made through the organ, for 
the purpose of examination ; and while the oedema remained, it could be 
without difficulty displaced by pressure. On the contrary, several specimens 
in my possession of infiltration from inflammation, in consequence of typhous 
ulcerations, have but little changed (after being in alcohol several years), 
except in the superior portion of the larynx, where simple oedema existed. 
Whenever it is thus situated, or on the epiglottis, it is invariably the result 
of inflammation at some point below, with infiltration of pus throughout the 
areolar tissue involved. The only exception to this rule which can be con- 
ceived, might exist in some case where, at an anterior date, inflammation had 
existed and permanently destroyed the character of the tissue involved. 
Except under such circumstances, it would be impossible for oedema to accu- 
mulate sufficiently, from below upwards, to extend to the epiglottis without 
producing suffocation, from complete closure of the glottis below. Of forty 
cases of sudden death, given in the Guy's Hospital Reports for April, 1855 
(London Lancet, N. Y. edit.), one occurred from simple oedema glottidis, 
which terminated fatally within five minutes after the first difficulty arose ; 
no mention is made of any inflammatory appearances having been detected. 
Several cases are on record of non-inflammatory oedema of the glottis occurring 
after scarlet fever; one has been given by Bayle, which MM. Trousseau and 
Belloc regard as the only case (previous to their day), in which the oedema 
could be regarded as resulting from a non-inflammatory cause. M. De Le- 
No. LXIIL— July 1856. 6 



78 Emmet, (Edema Glottidis from Typhus Fever. [July 

siauve has given two, which occurred towp.rds the close of cardiac disease, and 
of thirty-four other cases which had the affection developed during convales- 
cence from different diseases, seven had suffered from a continued fever. 
Sestier collected one hundred and ninety cases, of which number eighteen 
had had typhoid fever ; it would be interesting to know what proportion of 
these resulted from ulceration of the larynx in consequence of typhus de- 
posit. Those given by M. De Lesiauve seem to have occurred after the 
primary disease had subsided ; this is not the case, as we have seen in laryngo- 
typhus, although occasionally asphyxia takes place as suddenly as in the other 
form. M. Valleix remarks : " Furthermore, oederna of the larynx is most 
frequently only the termination of ulceration of the larynx, the process of 
the one necessarily occasioning the other." There are some writers who have 
expressed a doubt as to the occurrence of ulceration in the larynx from any 
other cause than those produced by syphilitic and tuberculous deposit. Cop- 
land, in his Dictionary, under the head of Laryngitis and oedema glottidis, 
states : " There are five cases, however, quoted by MM. Trousseau and Belloc, 
in which it is supposed to have arisen from an affection of the larynx, attended 
with ulcerations of its investing mucous membrane, while the lungs were free 
from tubercles. M. Valleix and Louis question the authenticity of these 
cases. It is, moreover, worthy of remark that Trousseau and Belloc do not 
appear to have themselves observed a single case of laryngeal ulceration with- 
out pulmonary tubercles." In Rokitanslcy's Pathological Anatomy we find : 
« Laryngo-typhus is with us an unusually common and extremely unfavourable 
symptom in many epidemics of typhus." In an article on laryngitis of typhus 
fever (Ranking s Abstract, 1847, art. 4), by Dr. Frey, mention is made of 
the very frequent occurrence of lesions of the larynx, threatening fatal ob- 
struction to the glottis from mucous inflammation, fibrinous exudation, deposit 
of typhus matter, &c. The editor writes : " We do not call in question the 
accuracy of the above remarks, suggestive of the frequent occurrence of 
laryngeal complications in fever in Edinburgh, but they are certainly (such at 
least as would require laryngotomy) far from common elsewhere." 

The earliest description of oedema glottidis I have been able to meet with, 
in any of the journals to which I have had access, is a case in a boy, which 
came under the care of Dr. Farre, in 1806, and was reported by him (with 
several others) in the 3d vol. of the Medical and Chirurgical Transactions 
of London. 

In describing the case of " cynanche laryngea," he states : " A noise 
attended every respiration, which she (the mother) expressed by the mono- 
syllable — flip-flap. It seemed to her that something was lifted up every time he 
Ixreathed, and in striving to breathe, his head, body, and limbs worked," &c. 
st At the post-mortem examination, the oedema was general. The sacculi- 
laryngei were completely concealed, the greatest deposition of lymph having 
taken place at this part of the windpipe, by which it was so much narrowed 
that there was scarcely room for the point of a crow-quill to enter," &c, This 



1856.] 



Emmet, (Edema Ghttidis from Typhus Fever. 



79 



case is interesting in connection with the explanation I have given in refer- 
ence to the difficulty in expiration, when the oedema existed below the ven- 
tricles of the larynx. No mention is made as to the time at which the noise 
ceased, but as the boy became gradually insensible several hours before death, 
it is likely, as the effusion continued to increase, it did so as the parts became 
immovable from distension. No traces of inflammation seemed to have been 
noticed in the case. 

Among the Guy's Hospital Reports, published in the London Lancet 
(June 1, 1850, p. 670), is found the following, the only one on record, 
to my knowledge, presenting that curious and interesting condition after the 
operation of tracheotomy that existed in Case III, where artificial respiration 
was steadily maintained during five hours, before the function of respiration 
could be carried on unassisted. Although the primary exciting cause was 
different, the case is no less instructive, while it illustrates, by a second attack, 
the existence of difficulty in expiration, with oedema, resulting most likely 
from a debilitated condition. A boy, aged 4 years, swallowed some boiling 
water on the 5th of March. A few hours afterwards, he was admitted to the 
hospital, under the care of Mr. xllfred Poland, with symptoms of oedema 
glottidis. The difficulty increased to such an extent, that tracheotomy was 
performed before morning. " No benefit followed the operation ; indeed, it 
appeared to have extinguished the little flickering of life left in the child. No 
natural effort at respiration ensued; no air rushed in when the trocar was 
withdrawn from the canula; the pulse had already ceased to beat for some 
time; the surface of the body was perfectly cold, the face of a deadly hue, 
and the child lay a motionless and apparently lifeless body." Artificial re- 
spiration was performed at the rate of twenty-five inspirations per minute. In 
four or five minutes the pulse began to beat, and the surface of the body 
became warm, but still no other signs of life manifested themselves, and no 
effort was made at natural respiration. As soon as the artificial means were 
suspended, to ascertain if any inherent vital power was rekindled, the pulse 
ceased, and the child became cold. At the end of five hours and a half : 
" At last the child gave one natural gasp, drew in a long unaided respiration, 
and slowly expired the air. Then succeeded a short interval of repose, and 
a similar movement was repeated; when again came a very long pause, when 
the child was assisted by a puff down the canula. This happily succeeded; 
respiration became slowly established; the little patient began to rally, open 
his eyes, and become conscious." After forty-eight hours the tube was re- 
moved, but the opening was not closed until some twenty days or more after 
the operation. Soon after recovering, the child "took cold" — " great diffi- 
culty of breathing ensued, requiring efforts in expiration, which were chiefly 
made by the abdominal muscles. A peculiar crowing noise attended each 
expiration, and it seemed as if there icas some obstruction in the larynx about 
the vocal cords," &c. In consequence of the dyspnoea becoming so urgent, at 
one time the question was raised in reference to operating again ; the patient, 



80 



Emmet, (Edema Glottidis from Typhus Fever. 



however, improved, and finally recovered, having been forty days under treat- 
ment. In the first attack, the inflammation was very violent, with oedema in 
the superior portion of the larynx most likely — where it is usually found 
under such circumstances. At this time, if any difference existed between 
the inspiration and expiration, it was doubtless in the former act, although in 
the history of the case no mention is made in reference to this point. The 
exigencies of the case, it was thought, required an active treatment. Seven 
leeches were applied to the throat soon after admission, and calomel and anti- 
mony freely administered during the course of the disease. With the pros- 
tration consequent upon the operation, and remaining probably at least thirty 
clays in the hospital before the second attack occurred, it is not unreasonable 
to attribute it to the same condition as existed in the cases after typhus — in 
fact, simple oedema about the inferior portion of the larynx, from general de- 
bility, independent of any inflammatory condition. This is most likely true, 
as the case is reported with such precision in every respect that, had any other 
condition existed apart from the intermitting dyspnoea (probably increased by 
muscular action), it would have been mentioned. The existence of difficulty 
in expiration, with the seat of affection, must not be overlooked as a coinci- 
dence, if not a diagnostic mark of this condition. 

In the London Lancet (for July 17, 1830, p. 619) mention is made of a 
case which has also a bearing on the preceding one. M. Roux, in his practice 
at the Ilopital de la Chariti in Paris, operated for a case of oedema glottidis, 
the particulars of which are not given, further than the fact, that artificial 
respiration was maintained for several hours after the operation, before reac- 
tion was established. The necessity for this course was attributed to the 
circumstance of some blood passing into the trachea and bronchi during the 
operation. This is evidently a case in point, for had the quantity been suffi- 
cient to have endangered life so long from this cause, artificial respiration 
could neither have maintained it nor removed the difficulty. 

(Edema glottidis in connection with typhus fever, except as a result of 
inflammation, seems to have been entirely overlooked by all writers on this 
subject. The literature therefore on this point could have been dismissed in 
a few words, but it would have been incomplete, without considering in con- 
nection the occurrence of the affection under similar circumstances in other 
diseases. We have seen how large a proportion of the writers on this sub- 
ject have maintained its existence as resulting alone from an inflammatory 
cause. (Edema glottidis, by comparison, is indeed a disease of rare occur- 
rence under any circumstance, and in a large majority of the cases which 
have been recorded, it resulted doubtless from this cause. But that the other 
form, proportionately scarce, has never been met with by those who deny its 
occurrence, cannot, on this ground alone, be received as evidence that it never 
exists, while the testimony of the more fortunate minority, certainly is enti- 
tled to the greater weight. It is remarkable, under the circumstances, that 
so much labour should have been expended in endeavouring to prove that 



1856.] 



Trask, Cases of Rupture of the Womb. 



81 



simple oedema cannot occur in the larynx, as it does undoubted!} 7 from de- 
bility in other portions of the body, while the arguments advanced in proof, 
without exception, are either wanting in force, contradictory, or unsustained 
on true physiological grounds. 

113 Fourth Avenue, New York. 



Art. III. — Cases of Rupture of the Womb, with remarks: being a Sequel to 
a Monograph upon this subject, in this Journal for January and April, 
1848. By James D. Trask, A. M., M. D. ; of White Plains, New York. 

In a paper published in the Nos. of this Journal for January and April, 
1848, we presented an analysis of three hundred and three cases of rupture 
of the womb. Since its publication, we have obtained access to some authori- 
ties which were not then within reach, especially the essay of Duparque ; and 
we have gathered, from this and other sources, over a hundred cases addi- 
tional to those embraced in our previous communication. "We have thought 
that a brief analysis of such of these cases as have been already published, 
and a somewhat more extended history of several cases which have been com- 
municated to us, might prove useful as an addition to what has already been 
presented. We propose to give a summary of the results of these and of 
the cases in the former paper, taken as a whole. It is possible that, in some 
instances, the same case may be reported more than once, in consequence of 
the occasional imperfections of the references, though great care has been 
taken to avoid this source of error. 

Rupture during Pregnancy. Recoveries. 

Case CCCIV. A woman had the abdomen and womb torn open, trans- 
versely, by the horns of a bull. The child escaped from the aperture, with a 
large quantity of blood. It was not until an hour afterwards that the funis 
was cut. It lived eight hours, and the mother recovered perfectly in six 
weeks. (Lechaptois, par M. Deneux, Essai sur les ruptures de la Matrice, p. 
35. See Duparque, p. 20.) 

Case CCCV. In a case similar to the above, it was necessary to increase 
the size of the opening, in order to extract the contents of the uterus. Re- 
covered completely in less than forty days. (Schmucker, Melang. de Chirurg. 
Ancien. Journal de Med., t. lxvi. p. 354. See Duparque, p. 21.) 

Case CCCVI. At seven months she fell from a tree ; motions of child 
ceased, and she suffered for a month. Four months afterward, felt a movable 
body in the abdomen; soon had bloody discharges, with some portions of hair; 
health good. Thirteen months from the fall, she was confined. Following 
the accouchement, an abcess formed, from which the remains of the first child 
escaped. Recovered perfectly. (M. Bochard, in L'Ancien. Journ. de Med., 
t. v. p. 42. See Duparque, p. 72.) 



82 



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Case CCCVII. . Mi. 27. Fifth month; second pregnancy; fell from a 
tree, and felt a tearing pain in the lower part of the abdomen ; was confined 
to her bed for two months, and for five years had great irritation of the blad- 
der. When fifty years old, she expelled a calculus from the bladder, formed 
around a bone ; and soon after, twelve similar ones were withdrawn from an 
abscess below the neck of the bladder. She recovered. (M. Lessieux, Extr. 
des Bull, de la Soc. Med. d' Emulation, 1822. See Duparque, p. 92.) 

Case CCCVIII. Mi. 24 years. Had undergone Cesarean section about 
three years previously. Was found with symptoms of bilious colic; five 
hours afterward, complained that she was " tearing in two," and said some- 
thing had torn inside of her; the os was slightly patulous, and there was 
some hemorrhage from it. Upwards of forty-eight hours afterward, the foetal 
heart was distinctly heard. In three weeks was about the house ; vaginal 
discharges came on, with great constitutional irritation, and the foetus was 
removed, by gastrotomy, three months and six days from the rupture. There 
was an opening through the uterine walls. Recovered. (H. A. Bizzell, 
Amer. Journ. Med. Sci., Jan. 1856, p. 79.) 

Rupture during Pregnancy. Deaths. 

Case CCCIX was hurled into the air by the horns of a bull, her abdomen 
and uterus having been torn open. The child, escaping from the womb, fell 
upon the ground at the same instant with the mother; the child lived a 
month, the mother died in thirty-six hours. (Sue, Essai Historique sur V Art 
des Accouchement, t. i. p. 209, from Duparque, p. 19.) 

Case CCCX. iEt. 26 years. For three hours had had violent colic pains, 
with great restlessness; the face pale; skin covered with cold sweat; the pulse 
small and intermittent ; belly not hard or tender. Her husband reported that 
she had missed her catamenia for three months, and had lately been indis- 
posed ; in the evening she ate cauliflowers, and at night was taken with colic, 
vomiting, &e. During this conversation she turned upon her side and died- 

Post mortem. — Great effusion of blood ; a foetus of about two months had 
escaped from a rent in the left cornu of the uterus — edges of the rent thin 
and brittle — walls were four or five lines thick, excepting at the rupture, 
where, for the space of an inch, they were very thin. (M. Collineau, Journ. 
Gen. de Med. See Duparque, p. 49.) 

Case CCCXI. 2&t. 30 years ; mother of five children and had several mis- 
carriages. When three months pregnant, made a misstep, and, in the effort 
to recover, felt violent pains in the womb and sinking; great prostration. 
After five days' repose, she got up, and was about the house for a month, 
when similar depressions returned, and she died in three days. 

Post mortem. — A rent of one inch at the fundus, near the insertion of the 
right tube, corresponding with the situation of the placenta ; womb contained 
a foetus of three to four months. (J. B. Puzin, These, 1809. See Duparque, 
p. 51.) 

Case CCCXII. iEt. 30 years; three months pregnant; always had good 
health. While at her needle-work, she became faint and sick with sudden, 
intense pains in the stomach. When called, at 9 P. M., she was in extreme 
pains; nauseated; pulse small and feeble; had eaten heartily of tripe, a few 
hours before. Gave a full dose of opium. 11 P. M. Excessive depression ; 
almost pulseless; dying evidently from internal hemorrhage; now, had occa- 
sional pains in back, but chiefly in stomach ; no vaginal discharge. Died six 
hours from the attack. 

Post mortem. Immense coagula; a perfect ovum protruding through a rent 



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in the uterus, which was firmly contracted ; was about four months gone ; 
uterus " excessively pale and soft, indeed, I could easily tear it asunder; rent 
antero-posterior, as regards the fundus; no cause could be ascertained." (F. 
H. Warren, Loud. Med. Gaz., 1851, vol. ii. p. 1103.) 

Case CCCXIIL Mt 28 years; a single woman ; slightly indisposed for 
some days ; for last few hours had complained of pain in abdomen, and sick- 
Bess, which became suddenly aggravated, when the physician was sent for, 
who found her in articulo mortis. 

Post mortem. — About seven months pregnant ; much blood in the cavity of 
the peritoneum ; rent in fundus of womb four inches long, and gaping — the 
placenta prevented escape of the foetus ; womb " no thicker than a sheet of 
writing-paper for at least a distance of two inches around the rent ; liquor 
amnii had not escaped. (J. "Watson, L. Lancet, 1853, vol. i. p. 267.) 

Case CCCXIY. JEt. 28. Admitted at full term; second pregnancy; good 
health. At seventh month she fell and shook herself violently, but no dis- 
turbance followed. Two weeks after admission, got vomiting, with restless- 
ness; pretty strong pains followed, during one of which she felt a severe 
"crack in the back/' as if something had given way inside; os nearly closed; 
pains ceased ; died next day ; no expulsive pains. 

Post mortem. — In abdomen, blood; and a full-grown foetus, dead several 
days. Kent from centre of fundus, posteriorly along whole length to the os; 
uterus seemed to be perfectly healthy; no softening; no appearance of pre- 
vious inflammation ; surrounding parts healthy; usual predisposing and ex- 
citing causes absent. (T. F. Brownbill, Lond. Lancet, 1848, vol. ii.) 

Case CCCXY. JEt. 25. Eighth month; fell on a step, and struck the 
abdomen; she felt as if something had burst. Xow the movements of the 
child could be felt on the right side, very close to the skin. Died on four- 
teenth day. 

Post mortem. Rent at the fundus, on anterior surface, one inch below the 
summit, extending transversely from side, and from four to five inches in 
length, and great loss of blood ; uterus and peritoneum of a dark green colour. 
(highly' s Obstet. Med., p. 217.) 

We have eleven additional cases of rupture during pregnancy, which, added 
to the thirty- eight previously reported, make forty-nine cases. Of these, Cases 
CCCIY, CCCY, CCCYI, CCCYII, CCCIX, and CCCXT, were of traumatic 
origin; in the remaining four, the accident was spontaneous. These, added 
to six among the above, make thirteen of traumatic origin. 1 

In Case CCCYIII, the remarkable fact is stated, that two days after the 
apparent occurrence of the rupture, the pulsations of the foetus ceased to be 
heard. 

Recoveries at full term of Pregnancy. 

Case CCCXYI. Sixth labour; contracted pelvis. Seven hours and a 
half after escape of waters, the uterus was fully dilated; pains very powerful; 
and she complained of pains at right sacroiliac junction. In a half hour, 
pains ceased entirely. Four hours after this, some hemorrhage ; perforation 
attempted ; delivery completed at end of four hours. Rent oblique, in direc- 

1 la Case XXVI, as we are informed by Dr. Bond, in a private communication, the 
patient's foot slipped, -while she was leaning against a barrel, and that she came with 
a good deal of force against the barrel. 



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tion of right sacro-iliac junction ; but little collapse. Recovered after many 
weeks. (Dr. Inglebijs Obstet. Med., p. 212.) 

Case CCCXVII. Was first seen after being in strong labour thirty-six 
hours; pains had suddenly ceased; os dilated; the foetus partly in the peri- 
toneal cavity, and high up. Delivered at once by turning. Rent on right 
side, from the cervix nearly to the fundus ; placenta and coagula removed ; 
very considerable depression; menstruation returned at the end of five 
months. {Ibid., p. 214.) 

Case CCCXVIII. JEt. 35. Primipara; extreme rigidity of os; pains 
strong for thirty-six hours, when the os being dilated to half a crown, and 
" hard as marble," with excessive violence of pains, the cervix was felt sud- 
denly to give way to the touch, and to split asunder; delivery took place in a 
few minutes. (Perfect's Cases, vol. ii., CXLIX.) 

Case CCCXIX. After delivery in the usual way, the intestines could be 
very distinctly touched, having descended through a rent in the fundus. The 
surgeon replaced them, and held the hand in the womb until it was suffi- 
ciently contracted to prevent any further hernia of the bowels, and she re- 
covered perfectly. (Rungius, Instit. Chirurg., pars sec, p. 728. See 
Duparque, p. 167.) 

Case CCCXX. JEt. 16 J years. Primipara. After three days of severe 
labour, the os partially dilated. Forceps were applied. After forcible trac- 
tion, the head was suddenly forced into the pelvis. The cervix was torn from 
the vagina upwards. Recovered. (Duparque, p. 187.) 

Case CCCXXL The entire ovum passed into the peritoneal cavity. After 
many months, portions began to escape by the anus. After her death the 
remainder was found in contact with an ulceration into the colon. The rup- 
ture of the womb was nearly cicatrized. (M. Fleury, Rec. per de la Soc. de 
Med. de Paris, t. iv. p. 268. See Duparque, p. 235. 

Case CCCXXII. JEt. 32 years; delicate; third pregnancy. Somewhere 
about twenty-four hours from beginning of labour, three accoucheurs sepa- 
rately attempted the application of forceps and version, occupying several 
hours. Eight hours after this, delivered by perforation, occupying three- 
fourths of an hour, with but slight fatigue. A rent detected to the right, 
and behind, at the junction of the vagina; recovered in a month. (M. La- 
chapelk, t. Ill, p. 179. See Duparque, p. 288.) 

Case CCCXXIII. JEt. 28 years; strong, well formed, primipara; had 
been in labour five days; waters escaped four days; many attempts at de- 
livery by forceps and version; extreme prostration; perforation, with much 
difficulty in extraction ; vagina separated from uterus in the whole of its pos- 
terior half. Recovered. (Ibid.*) 

Case CCCXXIV. In April, 1847, I was summoned in great haste to meet 
Dr. M. The patient was very fat, about 30 years old, and in labour with 
her seventh child. The pains had been severe, and then ceased, with a cry 
from the patient that something was the matter. The head receded; the 
pulse was 124, and she became restless. I passed my hand to the head; 
attempted to bring it down with forceps, and failed. I then passed in my 
left hand, and discovered a rent in the uterus opposite the linea ileo pectinea, 
of about four and a half inches, and the nates and feet had passed through it 
and among the abdominal viscera. I reached the feet, and delivered her. 
The placenta came away with the child. She recovered, and continued well 
for years, and died a year since in consequence of erysipelas. (Communicated 
by Prof. Willard Parker.) 

Case CCCXX V. JEt. 42 years; large and corpulent; mother of nine; 



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unusual pain in uterus from one to two months; labour slow; pains strong, 
at long intervals. When os fully dilated, and head almost in perineum, she 
suddenly exclaimed, " What a cramp I have in my belly I" Expulsive 
pains ceased; an opiate given; great prostration; the head receded, and the 
child could be felt in the abdomen; was delivered with considerable difficulty. 
Rent oblique, from near the fundus toward the left; inflammation; recovery. 
(James Church, L. Lancet, vol. i., 1849.) 

Case CCCXXVI. Mi. 37 years; muscular. When in labour six or eight 
hours, on getting into bed had a tremendous pain, and a loud-cracking sound 
heard ; pains ceased, and she was believed to be dying, but as she was living 
six hours afterwards, Dr. P. was sent for. Extreme prostration, and child 
felt through the abdomen; delivered her easily by forceps. There was hernia 
of the intestines ; intense inflammation followed, and she recovered with ap- 
parently but little care. (Dr. Prassart, from Caspar's Wochenschrift, 1847. 
See Brit, and For. Med.-Chir. Rev., 1848, p. 279.) 

Case CCCXXYII. iEt. 80 to 35 years; strong, primipara. The edges of 
the os thin, hard, and very rigid posteriorly; anteriorly congested, and an 
inch thick. After thirty-five hours of energetic labour, the neck was torn 
almost entirely off, and the head descended. A year afterward she had a 
second child, after a labour of ten minutes. (Dr. W. P. Johnston, Amer. 
Journ. Jled. Sci., April, 1851, p. 342.) 

Case CCCXXVIII. JEt. 30; apparently very feeble; for two months 
had extreme anasarca; sixth child; os well dilated at the end of six hours; 
the back presenting, the breech was brought down, and after two hours of 
" very hard labour," the feet could be brought down ; every prudent effort to 
deliver by the feet; attempts to perforate failed. The foetus was dissected 
to the axillae, occupying two hours, severe labour continuing Rupture was 
suspected; as she was rapidly sinking, gastrotomy was performed. The head 
and placenta were in the peritoneal cavity; inflammation treated by cal. and 
op. By the eighteenth day the wound was healed, and by the twenty-ninth 
day could attend to domestic duties. (Dr. H. M. Jeber, from South. Med. 
and Surg. Journ. in Am. Journ. Med. Sci., April, 1851, p. 538.) 

Case CCCXXIX. Primipara; aet. 30 years; bilious temperament; good 
health; eight months and one week gone. After twenty-eight hours of labour, 
head pressed on perineum; one hour after this she was restless, and got up; 
on returning to bed, she fell back into the chair, screaming " 0, nurse !" 
Put her hand to the pit of the stomach, and gasped for breath ; could not 
bear a recumbent posture ; uterine tumour ill defined, and a swelling above 
it ; the head impacted ; delivery completed in forty minutes, the child living. 
The placenta was removed, " tremendous hemorrhage" followed, and the 
hand, when introduced, detected a rent at the upper right side of the fundus, 
antero-posteriorly admitting three fingers; no hernia; after thirty-five days, 
well. (Mr. Thomas, Prov. Med. Journ., 1846, p. 613.) 

Case CCCXXX. Mt. 38 years; fifth child; all previously born dead, and 
" cross-births." Called in consultation at 10 J A.M.; labour began at 4 
A. M. She was seen immediately; the os was fully dilated; the pains regu- 
lar, without any excessive strength. The breech presented to the left. 
About 8 A. M. the female genitals of the child were visible, and delivery was 
expected after a few pains. Suddenly he noticed the entire disappearance of 
the presenting part; the head had escaped into the peritoneal cavity. Dr. 
Gardner turned, the head was detained at the brim, the child was dead, and 
he perforated and delivered. The patient, by the great care of the attending 
physician, recovered. The laceration extended through the neck of the 



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[July 



uterus upward, and the bladder downward, and she will be shortly treated by 
Dr. Sims. Dr. Gr. attributed the recovery to the application of ol. terebinth, 
to the abdomen, which seemed to exert a magical effect. (Communicated by 
Dr. A. K. Gardner, New York.") 

Case CCCXXXI. Mi. 30 years; delicate; third labour; previous labours 
severe and protracted. After something over twelve hours of moderately 
severe labour, the os was found rigid, and equalling a quarter of a dollar; 
head at superior strait. Two hours after this, after a pain of great severity, 
she complained suddenly of great abdominal distress, and the pains ceased. 
She was left from midnight till morDing, when she was somewhat exhausted, 
and the head could not be felt. Ergot and stimulants given. Dr. Gr. was 
called in late in the afternoon; and found a rent upward and backward, the 
womb contracted, and no part of the child to be felt. He performed yas- 
trotomy, the child having escaped twenty-one hours previously. Was about 
the house in seven weeks. (Dr. John T. Grilman, Amer. Journ. Med. Sci., 
April, 1854, p. 401.) 

Case CCCXXXII. Excellent constitution; sixth labour; pains came on 
about 8 P. M. ; had been in labour about two hours and a half, with pains of 
increasing severity; the os fully open, and but slight advance of the head, 
when she went to stool, and there had two pains, the second causing intense 
agony and a burning sensation in the right side. She was certain that some- 
thing had given way within her; head receded; rupture diagonal; all but the 
placenta was in the peritoneal cavity. Turning declined. Next morning, 
(jastrotomy. Child hydrocephalic; rent enormous, and womb uncontracted. 
She was convinced that she should recover, and at the end of just a month 
she was at the wash-tub. (Dr. Mason, Am. Journ. Med. Sci., Jan. 1855, 
p. 281.) 

Case CCCXXXIII. Reached her after she had been in labour three days. 
She was pale and exhausted ; had suffered no pain for more than twelve 
hours. The shoulder presented; there was a laceration of the neck of the 
womb, through which the head only had passed. Delivered her immediately, 
with little difficulty; expected she would die soon; she recovered, and in 
eighteen months afterwards was delivered of a living child without assistance. 
See Case CCCXCVI. (Dr. H. A. Hartt, New York Journ. Med., Nov. 
1850, p. 330.) 

Case CCCXXXIV. Mi. 29 years; medium stature, strumous habit, good 
health, third child. Labour set in at 1 A. M. ; it went on favourably; be- 
tween 6 and 7 P. M. head began to press on perineum. On the passing of a 
pain not unusually severe, she exclaimed she had a " queer cramp" in the 
belly, different from anything before, and that she must rise up. She walked 
across the room three or four times, scarcely lamenting. On touching her 
pulse, found it 120. She lay down, but was restless; the head had receded; 
was surprised at the few symptoms of rupture. She said, that as the last 
pain passed off, the child gave three kicks, followed by the cramp; there was 
no hemorrhage, anxiety, or prostration. She remained sitting in a rocking- 
chair for twelve hours, without any marked decline. At 9 A. M. next day 
the child was turned, and delivered with ease to the head ; this could not be 
delivered even by forceps. Child was then detruncated, and a hook passed 
into the foramen magnum without success; eventually delivered after per- 
foration and removal of bones of the head. The omentum and intestines 
were distinctly felt, but there was no hemorrhage or dots; has been much 
prostrated, and not expected to live an hour. On eighth day put upon calo- 
mel and Dover's powder, blisters and tonics. The rent was at the juncture 



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of the neck and body. In four weeks from the accident she was in the 
street, and in nine weeks menstruated. (Dr. TV. H. Maxwell, AT. Y. Journ. 
Med., May, 1851, p. 328.) 

Dr. Maxwell has kindly favoured us with the subsequent history of this 
patient, which will be found in Case CCCXCYI. 

Case CCCXXXY. Mt. 32; robust; third labour. Labour began Decem- 
ber 30, at 3 P. M. ; foot presentation ; pains slow at first, became strong and 
frequent toward 9 P. M. About 11 P. M. a pain of great violence came on; 
a free flow of blood ; labour ceased immediately, and foot no longer to be felt. 
She remained that night, and the following day and night, with acute pain in 
the abdomen. "Late in the evening of January 1 (about forty-eight hours 
from rapittre), gastrotemy Was performed. The child could be felt high in 
abdomen ; a rent could be felt on a level with the brim of the pelvis, remain- 
ing open for a quarter of its length in the left side, and elsewhere obstructed 
by clots, &c." Child dead; but little fever followed; nothing remarkable 
occurred; she resumed her work in forty days. (M. Mazier, Journ. de Med. 
et Chirurg. Pratique, quoted in Bd in. Month. Journ. Med. Sci. } Feb. 1854.) 

Case CCCXXXYL An oblique, contracted pelvis; had borne two dead 
children; head became impacted at the brim. The pains, which were very 
strong, suddenly ceased; pulse sunk very low; a rupture felt at posterior part 
of the uterus; gastrotomy ; child dead, with a greatly enlarged head. Re- 
covered completely in five weeks. (J. F. Haider, Nederland Weekbl, Aug. 
1853, in Edin. Month. Med. Journ., Feb. 1854.) 

Case CCCXXXYII. Sixth labour; learned she had been in labour 
twenty-four hours; pains had been regular, but not severe; the membranes 
had ruptured a few hours before his arrival; head had pressed on perineum, 
and just on eve of expected delivery she felt something give way; the child's 
head had receded beyond reach, and pains had ceased. He found her with 
intense suffering; pulse rapid and feeble; respiration difficult; no pains; a 
large rent in front of uterus; the head remaining in the uterus; passed in 
his hand, and turned without difficulty; child dead; a large dose of laudanum. 
(Dr. Thos. Christie, in Canada Med. Journ., 1853; in Assoc. Med. Journ. ; 
Nov. 1853, p. 969.) 

Case CCCXXXYIII. July 6, 1851, was sent for by midwife about 5 
P. M., who had been with the patient since 11 o'clock A. M. The pains 
were then strong; os uteri quite dilated; the head did not descend, but rested 
on the brim of the pelvis. Saw her again at 8 J o'clock; found the head in 
the same position, the expulsive pains having ceased completely, although she 
complained of great cramps in the abdomen. I prescribed tinct. opii gtt 1. 
and left her for an hour and a half. On my return was informed that the 
laudanum had been rejected; she complained of excessive pain in the abdo- 
men. On examining, the head of the child had disappeared, and could not 
be reached by the fingers. On examining the abdomen externally, the child 
appeared high up, close to the diaphragm. From these facts I inferred, that 
when the expulsive pains suddenly ceased, a rupture of the uterus had taken 
place. I therefore introduced the hand, and having secured the feet, ex- 
tracted the child. It gave no signs of life ; the placenta was extracted with- 
out difficulty. She was extremely ill for several days; pulse small and 
rapid; constant vomiting; abdomen distended, and very painful; a very fetid 
discharge from the uterus, and considerable irritation of the bowels. I gave 
up all hope of saving her, but she finally was restored to health. (Dr. F. 
Chatard, Baltimore; communicated through Prof. R. H. Thomas.') 



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Cass CCCXXXIX. The wife of W. C, a milkman, 4th mo. 27th, 1852, 
with her second child. She had been delivered by forceps several years 
before, and had suffered severely from vaginal inflammation. Dr. W. had 
been in attendance two days. The labour had been regular and natural until 
the os uteri was dilated, and the head descended into the pelvis. It was 
then discovered that the further advance was prevented by two firm bands, 
almost semi-cartilaginous, nearly closing the outlet of the pelvis. The pains 
being strong and forcing, the doctor hoped the bands, thick as they were, 
would gradually soften and yield. In the course of the night the puio.s left 
her; he. could not learn whether very suddenly or not. At 6 o'clock this 
morning, Dr. K. being called, they agreed to send for me. I found her at 
7 A. M. with feeble pulse, little or no labour pains, tender abdomen; head 
down against the two thick semi-membranous bands. As agreed upon, I 
passed a sharp-pointed bistoury through the bands on each side of the vagina, 
dividing them freely from without inward. There was not much blood lost. 
Without delay I put on the forceps, and delivered her easily of a dead child. 
The placenta came down in a few minutes, and being withdrawn, rather more 
hemorrhage followed than was thought compatible with her safety. I passed 
my hand into the vagina, and at once encountered a knuckle of intestine, the 
descent of which was being promoted by a sense of bearing down. Taking 
the bowel between my fingers and thumb, I carried it through a rent which 
was found readily between the vagina and uterus. Upon attempting to with- 
draw the support of my fingers, the bowel again came through; I therefore 
prevented it by the fore and middle fingers within, while by gentle friction 
without I induced the uterus to contract so much as to close the rent. I 
withdrew first one finger and then the other, and the bowel did not follow. 
A large opiate, with calomel, was given. She said she was much relieved, 
and though we thought it right to tell her husband how desperate was her 
condition, and he did not conceal it from her, she boldly said, " I shall cer- 
tainly recover." For two days, no very serious symptoms occurred; on the 
third day, a chill, followed by high fever, tumid and tense abdomen, tender- 
ness and pain, obstinate constipation — in a word, severe peritonitis. With- 
out detailing the treatment, which was much as usual in such cases, it will be 
sufficient to say that she quite recovered in a few weeks, and has continued 
well. [Communicated by Dr. Richard II. Thomas, Professor of Obstetrics, 
University of Maryland.) 

Case CCCXL. Fourth child ; had been in labour twelve hours, but for 
four hours pains had ceased ; shoulder presented; turning effected with slight 
difficulty and delay; child dead. On introducing the hand on account of 
hemorrhage, " a transverse rent in the walls of the uterus, about three inches 
above the cervix anteriorly," was discovered, through which three fingers 
could be passed. Sero-sanguineous and purulent discharges continued for seve- 
ral weeks, with irritative fever and diarrhoea. Recovered, and has good 
health. (W. W. Duvall, M. D., Amer. Journ. Med. Sci, Oct. 1855, p. 542.) 

Deaths from Rupture at full term. 

Case CCCXLI. Mt. 35; seventh child; had been in hard labour ten 
hours; os equalled a half-crown piece; hydrocephalic foetus diagnosed; pains 
violent ; was about to perforate, when, on being allowed to stand up, she had 
a singular sensation, with pain below the heart, with fainting and vomiting, 
and pains ceased; head receded; great prostration; child found among the 
intestines; feet brought down. She died before delivery of the head, twenty 



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minutes after getting out of bed. Rent from side to side of womb. (W. 
H. Borham, Lond. Lancet, 1848, vol. ii. p. 551.) 

Case CCCXLII. iEt. 32; stout, sixth labour; had pain in right side since 
last confinement, and not generally so well as before; drinks hard; had acute 
pain in right side and back four days before labour came on. Pains began 
at 3 A. M. ; at 6^ A. M. os larger than a shilling; soon membranes ruptured, 
but in half an hour the head had receded beyond reach ; she had felt a sud- 
den cramp, or something snap, with a tearing, and distinctly heard it ; had 
frequent returns of the cramp, with an effort to strain; pains subsided gra- 
dually, and ceased at 8* A. M. Slept quietly; got up through the day two 
or three times. At 5 P. M. severe pains after oil; no complaint of debility; 
voice firm; slight sanguineous discharge; venesection, &c; turning, appa- 
rently at night; delivery difficult; head partly through the rent. Death in 
thirty-six hours from rupture. (Dr. Reid, Lond. Med. Gaz., 1845, Part L, 
p. 685.) 

Case CCCXLIII. iEt. 28; fourth child; narrow pelvis; had been in 
labour twenty-four hours, and turning unsuccessfully attempted; found in a 
state of collapse, without pain. The breech could be felt in the peritoneal 
cavity; the head presented per vaginam; head opened. The rent had been 
felt in passing in the hand. Died on fourth day. (Dr. Smallwood, St. Mar- 
tin, Canada, in Brit. Amer. Journ., 1848, quoted in Prov. Med. Journ., 
1848, p. 138.) 

Case CCCXLIV. Sixth child, all preternatural; distorted pelvis; shoulder 
presentation; arm had been amputated after ineffectual attempts to turn; 
womb ruptured; I brought down the feet. Rent in back part of body of the 
womb, obliquely up toward right broad ligament. Died on fourth day. (F. 
Ramsbotham's Reports, Lond. Med. Gaz., 1843, iv. p. 463.) 

Case CCCXLV. Twelfth child; foot presentation; uterus did not act 
violently, and no force used in extraction. Child dead; lived three hours 
after delivery. (Ibid., p. 486.) 

Case CCCXLVI. Had a family; head; died some time before help arrived; 
child and placenta in peritoneal cavity. (Ibid., p. 519.) 

Case CCCXLVII. In expulsion of a blighted ovum suffered transverse 
rupture at the cervix, above the os. Believed herself near full time, and had 
hemorrhage for two weeks previous. A surgeon removed the ovum from the 
vagina, and detected the rent. The uterus had not exerted itself greatly. 
The rent almost across the womb, and did not involve the peritoneum. (Ibid.) 

Case CCCXLVIII. Contracted pelvis; fourth child; membranes had been 
broken forty hours, but no strong pains. Symptoms of exhaustion occurred 
rather suddenly, and found her cold, with extreme depression. Laceration 
felt in anterior part of cervix; feet presented, and child was extracted after 
perforating the head ; placenta and body among the intestines. Head had 
originally presented. Dr. Ramsbotham has known this evolution in another 
instance; time of rupture unknown. 

Post mortem. — Rent transverse; six inches in length; walls of uterus 
around it easily tore, and the whole organ much softened; evidence of in- 
flammation in abdomen of some standing. (Ibid., p. 330.) 

Case CCCXLIX. Tenth child; labours always lingering; pelvis dis- 
torted at the brim; head presented; rupture eight hours after membranes 
broke; pains not strong; no tearing sensation at the rent; child and pla- 
centa in the abdominal cavity; delivered by the feet; rent horizontal in 
anterior part of cervix; child dead; she died in twenty-four hours. (Ibid., 
p. 369.) 



90 



Trask, Cases of Rupture of the Womh. 



[July 



Case CCCL. Eighth child; head presentation; died in forty minutes after 
delivery. (Ibid.) 

Case CCCLI. Pendulous abdomen; head rested on pubis out of midwife's 
reach; was delivered after use of ergot; at the end of forty-eight hours, 
feverish, with vomiting, swelling, &c; "the black vomiting, soft but tume- 
fied abdomen, the absence of pulse, and the coldness of the body, led me 
instantly to hazard the opinion, that the symptoms were the result of lace- 
ration." She died almost immediately. An opening in the vagina behind, 
communicating with one in the uterus, probably made by a finger. (Dr. In- 
gleby, Obstetric Medicine, p. 206.) 

Case CCCLII. Had several very difficult labours. Before twelve hours 
the os was fully dilated, and a consultation held previous to perforation; the 
head receded, laceration having taken place. Turned. Died. 

Post mortem. — Cervix and vagina lacerated extensively just opposite the 
promontory of the sacrum. Brim measured three inches. (Ibid., p. 207.) 

Case CCCLIII. Third labour; strong pains; soon after rupture of mem- 
branes, they grew weaker. Arm presentation ; turning under very feeble 
pains. A laceration detected in a few hours. Died about twelve hours after 
rupture. 

Post mortem. — Rent from cervix upward, for five inches; uterus thin and 
weak at rupture, but thick and strong elsewhere. (Ibid., p. 208.) 

Case CCCLIV. Third child. Turning, effected with much difficulty, 
several hours after unsuccessful attempts at delivery. Bent of cervix into 
the vagina detected, and the peritoneum found extensively detached. (Ibid., 
p. 209.) 

Case CCCLY. Eighth child. Labour began at 1 A. M.j 10 A. M. of 
next day, very much exhausted with vomiting, &c. Head had been impacted 
the day before ; now free ; perforated, but could not be extracted. Died in a 
few minutes. 

Post mortem. — Bent anteriorly, for two-thirds the length of the womb. 
The edges were not thinner than the surrounding parts; the contents of the 
womb in the abdomen ; contracted pelvis. (Ibid., p. 215.) 

Case CCCLVL Fifth child. Six weeks before labour, she fell down 
stairs, and got a violent blow upon the left side of the belly, and she ex- 
claimed that something had given way and broke ivithin her. From that 
time, had acute pains in hypogastrium. On the eighth day of labour, the os 
was somewhat dilated, the membrana broken, the pains weak and few. After 
being " nearly a week in labour," she was delivered by turning — foetus long 
dead. Died on third day. 

Post mortem. — Uterus ruptured, within an inch of its internal orifice, to 
extent of nearly four inches. (Perfect's Cases, vol. ii., Case 78.) 

Case CCCLVII. JEt. 27 years; good health; second child. At the end 
of twenty hours, the pains having been very severe, even when under the in- 
fluence of ether, there was cessation of the pains, and vomiting of greenish 
fluid, and a knee projecting directly under the integuments,, near the fundus. 
Pulse small, and not to be counted. Perforation. The head did not recede. 
Delivery very difficult. Died on fifth day. 

Post mortem. — Bent across the anterior wall of the cervix, just below the 
os internum. (Dr. Cabot, Amer. Journ. Med. Sciences, July, 1851, p. 70.) 

Case CCCLVIII. iEt. 40 years. Had repeated hemorrhages of late. 
Premonitory symptoms of labour during the day; waiting for real labour, 
when she had a single, most violent pain, which felt as if something had 
given way within her ; great prostration ensued ; the os was slightly dilated ; 



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Trask, Cases of Rupture of the Womh. 



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the placenta presented. The head and arm could be distinctly felt, as if pro- 
jecting through. No part of the child could be felt per vaginam. The rent 
was in the uterus. Died in ten hours from rupture, undelivered. (Dr. Wm. 
Rankin, Amer. Journ. Med. Sciences, Oct. 1853.) 

Case CCCLIX. Sixth child. Suddenly felt a violent pain, and immedi- 
ately the waters escaped with a great quantity of blood, from a rent in the 
inferior and right side of the womb, by which the body escaped into the 
peritoneal cavity while the head descended into the pelvis. The edges of the 
rent were firmly contracted about the neck. She died undelivered, in twenty- 
four hours. (Leclerc, Ancien. Journ. de Med., t. xxv. p. 522, from Du- 
parque, p. 125.) 

Case CCCLX. JEt. 40. Sixth pregnancy; all her previous labours 
severe. Died after three days of suffering; the fundus was rent; the foetus, 
which was very large, had passed into the abdomen, with prodigious hemor- 
rhage. (Obs. Var. de Med., ii., Obs. xxx, from Duparque, p. 128.) 

Case CCCLXI. JEt. 27 years ; third labour; died after a severe labour of 
forty-eight hours, having presentation of the placenta; rent of uterus and 
vagina; child entirely in abdomen; womb at the rupture very thin, and torn 
into strips, much distended ; the rest of the womb contracted and entire. 
(Nauche, Des Malad. de V Uterus, p. 216, from Duparque, p. 129.) 

Case CCCLXII. Arm in the vagina. On introducing the hand for turn- 
ing, a rent was felt, two inches in length ; but, as no part of the foetus was 
engaged in it, turning was completed. Died on the fiftieth day, when an 
optning, at the left cornu, communicating with an abscess. (B. M. Planchon. 
See Duparque, p. 132.) 

Case CCCLXIII. A tearing felt during labour, and the pains instantly 
ceased. A living child was delivered by the "usual means/' A large rent 
in the side of the womb, which was apparently in a scirrhous state. Died in 
a few hours. (Mad. Lachapelle. See Duparque, p. 137.) 

Case CCCLXIV. Contracted brim ; pains severe ; head advanced. There 
was excessive sensibility of the abdomen. In about twelve hours there was 
suspension of pains, and while she was carried on a bed, she complained of a 
tearing and extreme oppression ; the head could not be felt ; the placenta was 
expelled, and the feet felt in the womb, by which it was extracted. Hernia 
of omentum. Died in six hours. 

Post mortem. — Oblique rent; downward and forward; the edges of the 
rent in a scirrhous state. (Mad. Boivin, Obs. No. 111. See Duparque, p. 
137.) 

Case CCCLXY. Dr. Just. Frid. Ling, cited by Sue, speaks of a womb of 
which the fundus was extremely thick, while the right side was very thin and 
pierced by the feet. [Duparque, p. 143.) 

Case CCCLXVI. A case by Camper, in which the womb was so thin as to 
be pierced by the feet of the child. {Duparque, p. 143.) 

Case CCCLXVII. Mt>. 40 years; ninth labour; at full term, fell from a 
ladder; felt no more motion; labour-pains eight days after. Os dilated, foetus 
unfavourably placed. Next day, immediately after a very strong pain, seconded 
by violent efforts, an arm came down, and, at the same time, a noise as of a 
body bursting, was heard. On the third day of labour, the child could not 
be felt. She died next day. A very long rent was found in the right side, 
from which the head and one arm had escaped/' The uterus could not have 
been healthy. (Duparque, p. 153.) 

Case CCCLXYIII. A rupture at the fundus was recognized ; the child 
born ; no bad symptoms followed, and she nursed the child. Enlargement 



92 



Trask, Cases of Rupture of the JVomb. 



[July 



of the abdomen ensued, and in a few weeks she died. A rent was found in 
the fundus. (Ghambon. See Duparque, p. 163.) 

Case CCCLXIX. In carrying the hand into the womb, to detach the pla- 
centa, a rent was felt, and a large hernia through it. The intestines were 
returned, womb contracted, and she lived a month. (From Duparque, p. 
168.) 

Case CCCLXX. Mi. 28 years; strong; had natural delivery two years 
ago. After three days' labour, repeated attempts with forceps. Turning 
attempted, causing frightful suffering; and, after two and a half hours' trial, 
she was abandoned, and sent to the hospital. Pains had ceased ; uterus 
could be felt in front of the foetus ; head at the superior strait; the cervix 
contracted around the child's neck. On attempting to seize the feet, the 
entire child passed into the abdomen. She was abandoned. She retained 
her consciousness, and awaited the fatal moment. 

Post mortem. A longitudinal rent, starting at the vagina, inclining to the 
right side. Its edges were thick, and deeply ecchymosed. (Mad. Lachapelle, 
t. iii. p. 159. See Duparque, p. 180.) 

Case CCCLXXI. Had rupture of the membranes at 5 A. M.; at noon she 
ceased to feel the child move. For five hours repeated fruitless attempts were 
made, by three practitioners, to apply the forceps, and to turn, and she was 
sent to the hospital. Delivered by perforation, after failure to apply forceps. 
Died twenty-four hours after delivery. 

Post mortem. — A longitudinal rent, from cervix upward; the edges ecchy- 
mosed. (Ditto.) 

Case CCCLXXII. Mad. Lachapelle relates a case of a woman who died, 
undelivered, from hemorrhage. It proceeded from a vein beneath the peri- 
toneum which had been only slightly broken. The region of the rupture was 
remarkably thin, the rest of the womb thick. (Duparque, p. 185.) 

Case CCCLXXIII. Mt. 25 years. Lost blood, with the premonitions of 
labour. At the end of three days, was confined, in great pain, and died that 
day ; uterus torn in its left side, with laceration of uterine arteries and veins, 
from which there had been great hemorrhage. (Mem. de V Acad, de Chir. 
Recli. sur V Oper. Cesar., P. M. Simon. See Duparque, p. 185.) 

Case CCCLXXIV. # Good constitution ; third pregnancy ; head; after two 
days' labour, version, with much difficulty. In the neck, to the left and behind, 
was a deep fissure, which did not involve the peritoneum. Died, after a few 
weeks, having phthisis. (Mad. Lachapelle. See Duparque, p. 185.) 

Case CCCLXXY. Obliquity of the os; pains directed against the pubes. 
Death at the end of twenty-four hours. 

Post mortem. — The placenta and almost the whole foetus in the abdomen, 
with only part of the head in the uterus. The body of the womb was very 
thick, but around the rent it was scarce two lines in thickness. (Muller, in 
Collect, des Theses de Ilaller, from Duparque, p. 202. 

Case CCCLXXVI. Breech presentation. When in labour twelve hours, 
the os not being completely dilated, the anterior part of the neck separated 
from one side to the other, and the child passed immediately into the abdo- 
men. It was withdrawn with much difficulty, in less than two hours. She 
died five hours after delivery. 

Post mortem. — The pelvis was a little narrow ; the point, of the os sacrum 
passed through the posterior part of the womb. The inner and prominent 
edge of the pubis and ilia resembled an ivory paper-knife. (See Duparque, 
p. 206.) 

Case CCCLXXVII. Mt 26; delicate; third pregnancy; hydrocephalic 



if 



1856.] 



Trask, Cases of Rupture of the Womb. 



93 



foetus; rupture within twenty-four hours after commencement of labour. 
Hernia through the rent. Rent transverse, near the union of the vagina and 
uterus. Delivered by forceps; died almost immediately. (Duparque, p. 219.) 

Case CCCLXXVIII. Death after five hours of labour, with oppression, 
nausea, &c. The body of the child and the placenta were in the abdomen, 
while the head was still in the pelvis. Rent in posterior part, at junction 
with vagina. (Thibaut, de V Acad, de Rouen, from Duparque, p. 222.) 

Case CCCLXXIX. Mt. 28 years; third pregnancy; labour had not made 
sensible progress for twenty-four hours, when bloody mucous discharges took 
place; inexpressible uneasiness, and coldness of limbs. Twelve hours after 
this, she had a violent pain, followed, at once, by general sinking and cessa- 
tion of pains. Rupture detected twelve hours after, but she was left unde- 
livered for more than twelve hours, and died before it could be accomplished 
by forceps. 

Post mortem. — Rent in inferior, posterior, and lateral parts of the womb, 
involving the vagina to a great extent; child hydrocephalic. (M. Haime, 
Journ. Gen. de Med. See Duparque, p. 227.) 

Case CCCLXXX. Delicate; had three severe labours. After several 
hours of moderate labour, the os not being fully dilated, suddenly, without 
having had any severe pain, was seized with vomiting, &c. The presenting 
parts (the foot and head) had disappeared, and the uterus was empty. M.M. 
Devreux, G-ardien, and Roux being called in, found rupture of cervix at its 
union with the vagina. Turning was agreed upon in preference to gastrotomy, 
and done with little effort. Child dead. She died two days after. (Du- 
parque, p. 265.) 

Dr. Brainard, of Chicago, writes : " I have met with two cases of ruptured 
uterus. In one of these, 1 Case CCCLXXXI, there was a firm cicatrix across 
the vagina. The womb was torn transversely in front above the attachment 
of the vagina. After three days' labour the woman died, and being then 
called in to examine the body, I found the child in the abdomen. I have 
also ascertained, pretty certainly, that the cicatrix was produced by attempts 
to procure abortion. 

" The other case, Case CCCLXXXTT, occurred in a young woman, with, I 
think, her third child. She had very tedious and severe labours, and after 
several hours' pains, the head was well down in the pelvis. * * I found 
all the foetus, but one foot, escaped from the uterus; by that I delivered. She 
lived four days, when she died, apparently from strangulation of the intes- 
tines. " 

Case CCCLXXXIIL Mb 28 to 30 years. In the first labours the 
woman was delivered by taking the child from her by craniotomy. In the 
second labour, I was called in consultation on the third day of labour, and 
delivered the child, dead, of medium size, from above the superior strait, with 
the long forceps. I advised, in case of a third pregnancy, premature delivery. 
My advice was not adopted by her ; and the two physicians who attended her 
in the third labour permitted the natural violent throes to continue three days 
without assistance, or even attempting to deliver her. The womb ruptured; 
the child passed into the cavity of the abdomon ; mother and child were both 
lost. 

The post mortem, which I witnessed, demonstrated what I had rendered 
evident with the long forceps in her previous labours, that there was capacity 
enough in the pelvis, but in consequence of excessive curvature of the lower 

1 See this Journal for 1848, vol. ii. p. 113, Case LXIV. 
No. LXIIL— July 1856. 7 



94 



Trask, Oases of Rupture of the Womb. 



part of the spine, prominence of the sacro-lumbar junction, and non-conformity 
of the axis of the pelvis with the axis of the womb, the child's head could not 
be directed in and forced through the pelvis by the natural efforts. The ex- 
pulsive action being directed toward and upon the pubis, ruptured the womb 
at that point. (Communicated by Dr. Lewis Shanks, Memphis. Teun.) 

Case CCCLXXXIV. JEt. 38 years; fourth labour. When called at 
5 P. M. all pains had ceased an hour and a half before. Up to that time, 
pains regular and vigorous from the commencement of labour on the pre- 
ceding night; abdomen a little tender; pulse 85, warm; os very high, dilat- 
able; felt what was thought to be the head; suspected rupture; there was 
no tendency to collapse, or any marked symptom of so formidable an injury; 
child could not be felt under the integuments. By consent was left till 8 P. M.; 
head no longer felt; condition the same; pulse 92; had not had a single 
pain since 2 P. M. She refused to be delivered; some slight pains in about 
an hour. At 10 A. M. next day, she was dead. The abdomen at once 
opened; child and placenta among intestines; extensive rent of cervix. 
(Dex. Beau, Esq., Halifax, in Lond. Loncet, 1853, vol. i. p. 30 ) 

Case COCLXXXV. Fifth pregnancy; delivered after about five hours' 
labour ; no hemorrhage ; child long dead ; was left well and cheerful. Two 
hours after this he found her in articido mortis. She had, in the meantime, 
been very angry, and jusjt after this excitement, collapse ensued. 

Post mortem. — She had had uterine disease for years ; uterus uncontracted ; 
dark, extravasated appearance on the right side, at the right lateral ligament. 
Two pounds of blood had escaped; nothing unusual on the inner surface; 
cervix rugged and ulcerated. (J. Berncastle, M. D., Lond. Lancet, vol. ii., 
1851.) 

Case CCCLXXXVI. Wretchedly destitute; had a stillborn child after a 
most protracted and severe labour ; considerable hemorrhage, but no alarm- 
ing symptoms followed till the tenth day, when profuse bleeding came on 
and recurred, and she sank in five days. 

Post mortem. — Rupture in anterior and superior portions of uterus near the 
cervix; also an abscess at upper part of vagina. (G. J. Squibb, "The In- 
st'tute" Lond., Dec. 1850.) 

Case CCCLXXXVII. Was seen by a student at 3 P. M. In the evening, 
the right foot and hand brought down by a physician. Efforts at delivery 
ceased at about 11 P. M. ; after this she had no pains, but began to vomit, and 
sank rapidly. At 11 A. M. Dr. C. was called in, and finding the leg pro- 
truding through the vulva, discovered a laceration of the womb. We " pro- 
ceeded to turn," and delivered her of a dead child in half an hour, without 
much inconvenience to the patient, who felt relieved. Died in twenty-four 
hours, or thirty-six hours after the rupture. Hernia followed; placenta had 
passed into the abdomen. 

Post mortem. — Bent three inches up the cervix, and the same distance 
down into the vagina. (Reported by Dr. Conant to J¥. Y. Patholog. Soc. 
See N. Jersey Med. Rep., May, 1855.) 

Case CCCLXXXVIII. Delivered previously by craniotomy; narrow pel- 
vis. Was called in consultation at 11 A. M. on the 4th. She was taken in 
labour on the 1st; pains slight till evening of the 3d, when Dr. G. was sent 
for. Pains had been strong all night, but suddenly almost entirely ceased 
about 6 A. M. ; abdomen tender, not tumefied; constant grumous discharge ; 
head felt presenting very high up. Brought down a foot, and delivered her 
in a few minutes of a semi-putrid child. Shoulders and head delivered with 
some difficulty; the flattened head indicated great pressure; placenta came, 



1856.] 



Trask, Cases of Rupture of the Womb. 



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and womb contracted well ; prostration followed ; soon fell asleep; bid fair 
to convalesce till she expired suddenly at 6 A. M. next day. 

Post mortem. — Slight peritonitis; a rent in anterior surface, almost sever- 
ing the cervix from the body. Diameters of superior strait 2| in. and 4} 
in. (Dr. A. K. Gardner, in Amer. Med. Monthly, 1854, vol. ii.) 

Case COCLXXXIX. Robust ; ninth labour. Found child delivered, and 
mother prostrated from profuse hemorrhage. Labour had been rapid, but, 
as the head passed the vulva, there was a copious dash of blood, which still 
flowed; placenta not yet come away. In search of this the hand suddenly 
slipped through a jagged strictured orifice, and touched the intestines. She 
soon expired. For two or three months, though in apparently good health, 
she believed she would not survive this labour. " Could there have existed 
a softened or diseased spot — say of ulcerative inflammation in the fundus — 
which, during gestation, without giving rise to much general disturbance, 
could yet, through nervous depression, account for the woman's prescience, 
and which caused so weakened a state of the parietes as to cause them to give 
way during labour Y % (Dr. H. Ii. Worthington, in Amer. Journ. Med. &ci. 7 
Oct. 1854.) 

Case CCCXC. Mb. 40 years. Called at 10 P. M. She had for two or 
three months been subject to uterine hemorrhage, and for two weeks almost 
constantly. Had premonitory symptoms in the morning, and during the day, 
but no real labour until a short time before the visit, when she had a single 
most violent pain, and felt something give way. Great prostration, followed 
with tendency to vomit; great tenderness of abdomen, and coldness of whole 
body; pulse was imperceptible; constant sighing and restlessness; os was 
slightly dilated; presentation could not be felt. The head and arm could be 
distinctly felt through the parietes of the abdomen, as if projecting through a 
rent in the uterus. Fearing to deliver in her depressed condition, she was 
left to her fate, and died at 8 A. M. (Dr. Rankin, Amer. Journ. Med. /Set., 
Oct. 1853, p. 393.) 

Case CCCXCI. Healthy; set. 40; second gestation; labour pains came 
on in afternoon of 9th inst , when they became quite strong, and continued 
so till midnight, when she had one unusually severe, followed by a chill, and 
then ceased; 3 A. M. physician sent for, who found her cold and nearly 
pulseless; at 9. A. M. she was moribund; the child's head had remained 
down nearly to the external organ, but was not immovable. 

Post mortem. — Breech protruded four inches from the rupture; uterus con- 
tracted; placenta loose in abdomen ; rent extended from the os laterally to 
within an inch of the fundus. Thickness of walls at the rent was half an 
inch; at the opposite side one inch and a quarter. (Dr. Putnam; see Amer. 
Journ. Med. Sci., July, 1855, p. 50.) 

Case CCCXCII. Multipara; after a labour of twelve hours, had sudden 
excruciating pain, followed by distress at scrobiculus cordis, with vomiting, and 
rapid, feeble pulse. Delivered by forceps; placenta easily removed. Died 
in forty hours from rupture. There was in this no retrocession of head, nor 
external hemorrhage. (Ibid.) 

Case CCCXCI1I. Fourth child; afternoon, found os pretty well dilated; 
head could be reached only by an effort, by which membranes were ruptured; 
pains regular, and tolerably vigorous till midnight, when, as head was little 
inclined to descend, gave from half a drachm to a drachm of ergot in three 
doses. The pains became powerful, then less severe, then ceased; head re- 
ceded, and body passed out of the uterus, and could be felt there. The de- 
livery of the head required the crotchet, as the head was large and Sriti. 



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Trask, Coses of Rupture of the Womb. 



[July 



Died on third day. {Transact. New Jersey Med. Soc. ; see Dr. Storer's Rep. 
to Amer. Med. Assoc.) 

Case CCCXCIY. After labour had lasted several hours, pains almost 
entirely ceased; forceps failed; pains subsided; patient died in twelve to 
thirteen hours after first seen. 

Post mortem. — A rent four inches long in anterior part of fundus; the 
most of the child had escaped; the head unusually large. (Dr. J. M. Pugh, 
in Philad. Lancet, vol. i. See Dr. Storer's Report to Amer. Med. Assoc.) 

Case CCCXCV. Under care of midwife. Twenty-six hours after labour 
began she suddenly exclaimed that something had given way internally. 
Pains at once subsided; soon after a physician sent for, who remained all 
night, and bled her for rigidity of the os uteri. Dr. H. was called in the 
morning. The head had receded from the perineum beyond reach, and the 
child had escaped from the womb. She was sinking rapidly, and was left 
undelivered. 

Post mortem. — A rent several inches in length through the cervix. {Re- 
ported by Dr. H. A. Hartt, N. Y. Journ, Med., Nov. 1850, p. 330.) 

Case CCCXCVI. The same patient as in Case CCCXXXLV of recoveries. 
About three and a half years after first rupture Dr. H. was sent for, and 
reached her in the fourth day of her labour; was very weak; pulse 118, and 
feeble; respiration hurried. The hand had presented with severe pains, and 
twenty-four hours after they began, a snap was distinctly heard by her friends 
around her, the hand receded, and from that moment labour had been sus- 
pended. Found a large opening in the seat of the former rupture, and felt 
the child in the peritoneal cavity. Dr. H. turned and delivered, with great 
gentleness. She gradually sunk, and died thirty-six hours after delivery. 
{Ibid.) 

Case CCCXCVII. Mt. 35 years, seventh child. Labour progressed fa- 
vourably for four or five hours, when the pains suddenly ceased. She com- 
plained of chilliness and of great pain in the left iliac region; great pros- 
tration ensued. Death twenty-four hours after labour paius ceased. The 
head was low down, and an attempt to apply forceps was made just before 
her death ; the head did not recede after the rupture. 

Post mortem. — Foetus in peritoneal cavity; head firmly impacted in the 
inferior strait, and "it required no small amount of force to dislodge it;" 
placenta also had escaped. The rent was through the left portion of the 
neck, near its union with the vagina; edges irregular, and softened " from 
inflammation following the accident;" extensive marks of peritonitis. (Dr. S. 
S. Purple, N. Y. Journ. Med., Nov. 1852, p. 338.) 

Case CCCXCVIII. Fifth child; cailed in consultation at 3 A. M.; taken 
in labour near 6 P. M. the preceding evening; labour went on well till one 
hour ago; membranes ruptured at midnight; head advanced steadily till 
2 A. M., when she got a sudden cramp, and said something had given way* 
within her. Expulsive pains ceased; cramps continued; pulse feeble, irre- 
gular; respiration hurried; sense of suffocation; jactitation; green vomiting 
came on, and collapse, followed by death, a few moments before he reached 
her. The head was low down the vagina, and had not receded. 

Post mortem. — Foetus in peritoneal cavity with placenta, &c. ; body of 
womb contracted; on right side, near union with the vagina, was a large rag- 
ged rupture. " The parietes were softened, and required no great force to 
produce separation." {Ibid.) 

Case CCCXCIX. Same patient as Case CCCXXXIV. " Eighteen or 
twenty months after previous rupture, I attended her in labour of about eight 



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hours. The labour progressing, and the head descending, I was at the bed- 
side with the finger in the vagina, when suddenly there was a complete ces- 
sation of the labour; the head of the child receded. Up to this time there 
were no symptoms to indicate any but a favourable termination of the labour. 
I was watchful for the opportunity to aid my patient in her delivery by the 
use of the forceps. Before, however, the child, which was dead, could be 
removed from the mother, the latter expired. No post mortem could be ob- 
tained." (Communicated by Dr. W. H. Maxwell, New York.) 

Case CCCC. M&. 32 years; well made, pelvis well formed, and no ob- 
struction in passage; presentation natural; head of average size; seventh 
labour. Labour began at 4 P. M. ; until 5 J P. M. only ordinary pains, when 
the membranes broke after a violent pain, and about a gallon of water escaped. 
After this, there was no pain till 8 P. M., when she had two peculiar pains, 
and the head descended somewhat, according to the midwife; no pains after- 
ward; low and anxious, with great tenderness. At 10 P. M. she gave ergot, 
but with little or no effect ; 4 A. M. first seen by a surgeon. She was restless, 
exhausted, weak; rapid pulse; great pain and tenderness; forceps cautiously 
tried at 6 A.M., but failed to apply them; ergot given without effect. 
9 J A. M. 1 was sent for; great and immediate danger; perforated with con- 
siderable difficulty, from its mobility. Removed the placenta, and found ex- 
tensive rupture of posterior part of womb; the hemorrhage slight. Died at 
10 P. M , about eleven hours from removal of child. (W. Sedgwick, Land. 
Lancet, 1853, vol. i. p. 54.) 

Case CCCCI. After long-continued pains, the os very slowly dilating, she 
had a peculiarly acute pain, followed by collapse; os not found more dilated 
than before, and a fissure extended from it; a dead child was extracted by 
forceps, and the mother did not survive the operation. 

Post mortem. — A rent on left side, four inches in length; a cyst in left 
ovary of the size of a child's head, had prevented the descent of the head. 
There was no rupture of the peritoneum. (Dr. Ogier Ward, Land. Lancet, 
1853, vol. ii. p. 487.) 

CaseCCCCII. MIL 38 years; twelfth labour. Visit at 4 A.M.; os 
equalled a crown piece; head presented; membranes ruptured; roomy pel- 
vis; pains slack, but much complained of, and occasional vomiting. Up to 
7 A. M. labour progressed very slowly; the first stage completed, and as 
pains did not improve, gave ergot, repeated in a half hour; as little effect was 
produced, gave no more. The pains were not like labour pains, but much 
harder to bear, and confined to lower part of abdomen. About 8 J A. M. 
found head well down toward the perineum; pains moderate; but she now 
became violently excited; cried out that the " pain was dreadful, of an in- 
tense burning character, which never left her, and which she could not live 
under/' She persisted in getting out of bed, when she became suddenly 
pale and quite calm. Instantly suspected rupture; placed her on the bed; 
the head had receded; was almost pulseless; gave stimulants, and sent for 
forceps. It was now 10 A. M.; fell asleep, awaking occasionally. All pain 
had left her. About 12 she asked, " What was that crack 1" Immediately 
applied forceps ; she complained again of the burniug pain, and became very 
violent. In about half an hour, after much labour, just as I delivered the 
head, she expired. The shoulders defied all efforts to extricate them. 

Post, mortem. Breech and legs of child, with placenta, in peritoneal cavity; 
contracted womb low down in left iliac region, hid from sight; the rent ex- 
tensive in the anterior wall; child occupied entire pelvis, and could not be 
moved; probably a quart of coagula. As far as I could ascertain, there was 



98 



Trask ; Cases of Rupture of the Womb. 



[July 



no thinning of the uterus, or disease of the walls. (James Barron, Lond. 
Lancet, 1853, vol. ii. p. 587.) 

Case CCOCIII. Mi. 32 years; always healthy; ninth child; all had pre- 
sented unnaturally; pelvis roomy. Called at noon; had been in labour 
twenty-seven hours, and waters escaped for twenty-five hours; her whole np* 
pearance choleraic; pulse small and quick; great thirst; vomited coffee- 
ground coloured matter; had pains about once in fifteen minutes, crying out 
loudly at the accession of each ; os equalled a crown piece; presentation of 
something soft, could not be made out; excessive tenderness of bowels; ute- 
rus felt contracted to size at three months. The collapse was constantly in- 
creasing, and she was not delivered. She died at 6 P. M. 

Post mortem. — -Child weighed twelve to thirteen pounds; in the peritoneal 
cavity; placenta in the vagina; coagula in abdomen; the rent obliquely 
forward from near the broad ljgament down to the os; the vagina not torn; 
at the upper part the walls were two inches thick, at the mouth six-eighths of 
an inch. 

She had been seen by a quack seven hours after labour began, who intro- 
duced his hand, and during his manipulations she felt a sudden great pain, 
exclaiming something had burst, and that she was killed. Soon after this, 
vomiting commenced, and she continued to grow worse. (Chas. Vaudin, 
Lond. Lancet, 1854, vol. ii. p. 273.) 

Case CCCCIV. Thirty five years, strong and healthy, tenth pregnancy; 
had been in labour twenty-four hours, and the waters had escaped twelve 
hours; the os equalled a crown piece; vertex presentation; pains frequent, 
trifling, and ineffectual. She remained thus " without further evidence of 
completion of labour" for twelve hours. Turning was then performed, but, 
owing to some unknown difficulty, delivery could not be effected; collapse 
ensued; she died in twelve hours from his first visit. 

Post mortem. — Child a female, weighing eleven pounds, which had been 
extruded from the uterus, excepting the feet and legs ; rent in right side, 
close up to the os, and almost half through its circumference, the edges jag- 
ged and shreddy, the whole organ very dark, very flabby, and much softened; 
pelvis rather small, with a prominence of sacrum, which diminished the 
sacro-pubic diameter. (Ibid.') 

Cases CCCCV, CCCCVI, CCCCVIL " I have seen three other cases of 
rupture of the uterus, which all terminated fatally. One under the care of 
Dr. R., the rupture having taken place while the patient was attended by a 
midwife; she lived for several days. The second occurred to the late Dr. M.; 
the case terminated fatally in an hour after the accident. The third I saw 
with the late Dr. B.; she lived two or three days." (Dr. F. Chatard, Balti- 
more. Communicated.) 

Case CCCCVIII. JEt. 19 years, with her first child. She had a severe 
labour, and was constantly making immense efforts when her pains were pre- 
sent — greater than I ever knew to be made — so violent, that I repeatedly 
told her she would rupture her womb if she persisted. In the midst of a 
violent pain she shrieked out vehemently, and the pains became almost in- 
stantly less severe. She soon gave birth to a living child, but gradually col- 
lapsed, and in three or four hours died. The neck of the womb presented a 
rupture through its muscular coat an inch and a half to two inches in extent ; 
the peritoneal coat was safe. (Communicated by Prof. I). H. Storer, Boston.) 

Case CCCCIX. Mi. 40 years; had eight or ten children. Dr. T. had 
visited her repeatedly the day before in a slowly progressing labour; vertex 
presenting at the upper strait. The doctor left her at 10 P. M., directing the 



/ 



1856.] Trask, Cases of Rupture of the Womb. 99 

friends to send for him if the pains increased in strength and frequency. At 
4 A. M. he was sent for. While leaning with her pendulous abdomen upon 
a wooden stool, she had a violent pain, and cried out something had given 
way; some blood was lost from the vagina, and the pains did not return. 
The head of the child, which was very evidently at the upper strait at 10 
P. M., had now disappeared, and the pulse very feeble. I was sent for, and 
found the patient, between 5 and 6 A. M., almost pulseless, countenance 
sunken, skin bathed in sweat, steady pain in the abdomen, and almost mori- 
bund. Child's limbs could be felt through the abdominal walls. Having 
prepared myself for turning, and directed the frequent administration of 
brandy — the woman being quite sensible and able to swallow — I introduced 
my left hand into the vagina, and discovering a large rent on the left and 
upper part of its connection with the uterus, passed my hand into the perito- 
neal cavity, found the feet, and brought them without difficulty into the 
vagina and pelvis. Some bearing-down pains (abdominal muscles) now came 
to my assistance, and a large dead child was without any improper delay 
delivered. The placenta, and perhaps a pound or two of coagula and fluid 
blood, followed. The uterus was found to be contracted, and the hemor- 
rhage ceased. The pulse rallied; she expressed great relief; pain ceased; 
she took some laudanum, brandy, &c. In about eight hours she sank and 
died. 

Autopsy. — Flaccid, pendulous abdomen ; cellular tissue loaded with fat ; 
leucophlegmatic appearance of skin ; uterine walls unusually thick — softened 
and diseased in the right side, where a laceration, even in the semi-contracted 
state of the organ, measuring two and a half inches, had occurred; the vagina 
also forming a large part of the aperture. {Communicated by Dr. Richard 
H. Thomas, Prof, of Obstetrics, University of Maryland.*) 

Case CCCCX. Called to Johns, a coloured woman, 11th mo. 30, 1849, by 
Dr. K. She had been several days in labour, under the care of a midwife, 
who had repeatedly given her medicine. When Dr. K. saw her last evening, 
the pains had ceased suddenly, after having been very strong. She appeared 
much fatigued, but nothing very unusual attracted the Dr.'s notice. He 
directed refreshments and rest. He left her in charge of a midwife. About 
4 A. M., Dr. K. was summoned. She had rested none ; constant pain in the 
uterine region. She had been growing weaker, almost fainting; sick stomach 
and vomiting ; if not relieved must die. Stimulants were given, and I saw 
her at 8 A. M. Pulse very feeble ; countenance depressed and sunken ; shin 
cool, and bathed in sweat; abdomen and uterine globe tender and painful; 
mind clear, anxious for relief. Shoulder presented above the superior strait, 
and entirely in utero ; os very dilatable ; diagnosed rupture of uterus, without 
escape of child. The midwife prevaricated, and did not acknowledge what 
we afterwards ascertained to be the fact, that she had given ergot freely, 
before the pains ceased so suddenly. While we endeavoured to sustain, by 
brandy and water, Dr. R. proceeded to turn ; the feet were easily found, and 
the pelvis readily came down ; but the shoulders and head were large, and 
much delay and difficulty took place in their disengagement. She was very 
much exhausted. The placenta soon followed, with little hemorrhage. She 
continued to sink, and died in two hours. 

Autopsy. — Uterus contracted to nearly the usual size, twenty-four hours 
after delivery. A large rupture extended from the vagina, nearly half its 
length ; part of the vagina also lacerated. {Ditto.) 

Case CCCCXI. JEt. 32 years; had five premature confinements. Fourth 
mo., 1853, Dr. K. was called, at 7 P. 31., on 26th. Vertex presenting, 



100 



Trask, Cases of Rupture of the Womb. 



[July 



membranes gave way at 11 J P.M. Copious discharge of waters; head 
slightly advanced, " pains severe and expulsive ;" great restlessness. About 
1 o'clock A. M., while on close-stool, patient suddenly cried out with ex- 
cruciating pain in epigastrium; faintness; vomiting; total cessation of all 
labour pains; and frightful prostration ensued. Dr. K. at once concluded 
a rupture of the uterus had taken place ; had her properly placed, and sent 
for a medical man, who, with him, wishing my assistance, I saw her at 
4 A. M. She was greatly depressed ; almost pulseless ; extremities cold ; 
brandy was being administered freely; the head of the child being still within 
reach, I was able to use the perforator, and, after evacuating the contents of the 
cranium, to deliver the child with the crotchet, about 5 A. M. Hemorrhage, 
to a considerable extent, took place during the delivery, but ceased very 
much upon the delivery of the placenta. A rupture, large enough to admit 
the hand, was detected on posterior wall of the vagina and neck of the uterus. 
The patient continued very prostrate until 8 o'clock A. M., when reaction 
came on, and the pulse returned at the wrist, and warmth to the extremities ; 
strict quiet; anodynes. 28th. Bested well; no febrile excitement; a dose of 
oil. 29th. Rested well; pulse frequent; tongue brown; abdomen greatly 
distended; uterine region tender; was bled and leeched with relief. 30th. 
Better. From this time she improved until 5th mo. 9th, when she was de- 
clared to be convalescent, and the Dr. took his leave. On the 12th, Dr. K. 
found her suffering with throbbing pain in the right iliac region ; tympanitic 
abdomen ; small, thready pulse. May 13. Pain was relieved yesterday, 
followed by four or five dejections, containing blood and pus. She is now 
sinking. She died at 8 A. M., about twenty-four hours from the first com- 
plaint of pain in the iliac region, and eleven days after the occurrence of the 
rupture. " The patient clearly recovered," remarks Dr. K., " from the rup- 
tured uterus, as she had been for some days without fever, had good appetite, 
&c. She succumbed at last to the pelvic abscess, which discharged into the 
rectum." (Ditto.) 

Case CCCCXII. ML 28 ; admitted into Emigrant Hospital, June 22, 
1853 ; second child; labour commenced some hours prior to admission; the 
head presenting in the first position; pelvis of normal size, and the os uteri well 
dilated. The pains were extremely severe, until the head had passed through 
inferior strait, when they suddenly ceased ; the countenance became anxious, 
the lips livid, the patient complaining of dizziness only; pains soon recurred 
slightly, with very moderate expulsive force, and her strength began to fail; 
the pulse to increase in frequency ; and, as the axilla could be reached with 
the finger, it was introduced, and delivery completed by very slight traction. 
Child stillborn ; head large and tumefied ; liquor amnii greenish ; placenta 
in vagina; the uterus was contracted sufficiently for the bandage. The lividity 
of countenance remained, without any complaint of pain. Soon she became 
restless, with increased anxiety, and great exhaustion ; there was no hemor- 
rhage ; ice and brandy were given freely, but she died without reaction in an 
hour after delivery. 

Autopsy, twenty-four Jwurs after death, — Body well nourished; muscles 
pale and flabby. 

Abdomen. — Uterus firmly contracted. In the centre of the posterior por- 
tion of the neck of the uterus there was a rupture, from the os, an inch and 
a half in length on the internal surface, and an inch externally. The walls 
were flabby, of normal thickness. About two ounces of blood were found in 
the peritoneal cavity. The liver was large, and had a fatty appearance, as in 
cases of pulmonary phthisis, and quite friable ; kidneys exsanguined and soft. 



1856.] 



Trask, Cases of Rupture of the Womb. 



101 



The lungs were healthy ; the heart was flabby, with some fatty deposits on 
the exterior surface. There had been nothing peculiar in her condition, until 
the moment after her pains had ceased. 

The small extent of rupture, and the fatty appearance of the liver and 
heart, are worthy of regard, in connection with the occurrence of death so 
soon after so slight a lesion. (Communicated by Henry G. Cox, 31. D., Prof 
Theory and Practice Med. N. Y. Med. Coll., and formerly Clin. Lecturer on 
Dis. of Women and Children in State Emiyrant, Hospital.) 

Case CCCCXIII. Was seen after about two days' labour. For thirty-six 
hours after the rupture of the membranes, there was little or no pain ; pains 
then came on, and early delivery expected; but the pains ceased, vomiting 
came on, skin cold and clammy, pulse feeble, but the head did not recede, 
nor had any sharp, sudden pain been noticed. Was seen by Dr. C. seven 
hours afterward. A soft, fluctuating tumour, not the bladder, could be felt 
over the hypogastrium. The forehead was felt per vaginam ; forceps slipped 
off the head ; head perforated ; found hydrocephalic. She lived four hours 
after delivery, and eleven after rupture. 

Post mortem. — A half pint of blood in abdomen ; the peritoneal coat sup- 
posed to be torn in removal ; for, in the vicinity of the rent, the uterus was 
softened ; some lymph upon the uterus, and some pus between bladder and 
pubes. On opening the uterus, which was large, dark, and somewhat softened, 
a rent was discovered on the right side, anteriorly and near the neck; vagina 
intact. (Dr. Thos. F. Cock, N. Y Joum. Med., 1855.) 

Case OCCCXIV. Mt. 20 years ; third pregnancy ; one stillborn after 
severe labour; labour favourable until head had descended into the pelvis, 
when, about forty-one hours from the beginning of labour, the contraction 
ceased, but abdominal pains and vomiting were present. Forceps were applied, 
but head receded. When seen by Dr. C, seven hours after supposed rupture, 
she was livid, distressed, restless, vomiting; pulse 150; foetus felt through 
the parietes, abnormally distinct. There was a perforation in the perineum, 
and a band in the vagina, from a former labour. The finger could reach the 
head above the pubes; forceps and perforation inadmissible; gastrotomy 
mooted ; died undelivered, three hours afterward, or about ten hours after 
rupture. 

Post mortem. — Foetus entirely escaped from the uterus ; a knuckle of in- 
testine and a part of peritoneum showed marks of inflammation. A large 
transverse rent anteriorly, one inch above the os. The anterior vaginal wall 
extensively lacerated. Pelvis. Antero-posterior diameter at brim, four inches; 
transverse, four and a half inches. Inferior strait, transverse, three and a 
quarter inches; antero- posterior, four and a half inches. The pubic arch re- 
sembled that of the male; the linea ileo pectinea " quite sharp. " (Ditto.') 

Case CCCCXV. Multipara; set. 35 ; sixth child ; previous labour easy. 
Labour progressed slowly, with inefficient pains for thirteen hours ; pains then 
ceased. There was no outcry, or sensation of tearing, and the head did not 
recede. In about seven hours after this, she was found with a sunken, hag- 
gard, and pale countenance ; jactitation, with pain over whole abdomen ; pulse 
feeble, and 160; the head had not receded; portions of foetus distinctly 
felt on left side, but not on right; forceps tried, but bent, and head opened. 
She lived one and a half hours, or about eight and a half after rupture. 
(Ditto.) 

Case CCCCXVI. Mt. 37 ; seventh labour; good health. Labour began 
at noon ; doctor called at 7 P. M. ; pains expulsive, regular, and everything 
favourable. At 1| A. M., during a strong contraction, she complained of 



102 



Trask, Cases of Rupture of the Womb. 



[July 



acute pain in the back and abdomen to the umbilicus. Contractions ceased 
suddenly; she felt, during the pain, as if she should burst; she got upon her 
feet and fainted; countenance pale and sharp; surface cold and clammy; pulse 
rapid, wiry, and fluttering ; head had not receded ; vomiting of dark red fluid 
soon occurred ; forceps applied, and child delivered stillborn, followed by two 
or three quarts of blood. Child weighed 12 to 13 pounds. Previous to de- 
livery, the uterus had broken away, and occupied the right upper abdomen, 
and the foetus the lower and left— the head not having receded. Death in 
less than two hours after rupture. 

Post mortem. — Uterus excessively large and firm ; rent of two and a half 
inches of cervix and vagina, posteriorly ; uterine walls more than double usual 
thickness. Hence it is inferred the rupture occurred from immense muscular 
power, the foetus being large. (Ditto, communicated by Dr. E. IF. Owen.) 

Case CCCCXVII. Mt. about 30 years ; had had an instrumental labour, 
the second natural, the third fatal. Labour pains began in the morning. In 
the afternoon labour seemed near its close, but suddenly the contractions 
ceased, and had pain in epigastric region, with dyspnoea ; forceps used with 
great difficulty; head drawn down with difficulty by perforator. By successive 
efforts of three operators, foetus drawn down by a handkerchief around the 
neck. She died in an hour. 

Post mortem. — Large clots, and some blood in abdomen ; transverse rent 
anteriorly, at junction of uterus and vagina, three inches long, with ragged 
edges, and greatly ecchymosed; antero-posterior diameter of brim of pelvis 3^ 
inches; transverse, 5 \ inches; promontory very prominent. {Ditto; seen only 
after death.) 

Causes of Rupture. — The cases now presented afford still further confirma- 
tion of the views urged more especially by Dr. Murphy, and supported by 
our previous statistics, that a diseased condition of the womb is frequently 
met with in cases of this accident. Thus the uterus was thin and brittle in 
CaseCCCX. It was thin in seven, viz: in CCCXIII, CCCLXI, CCCXT, 
CCCLXVI, CCCLXXII, CCCLXXY, CCCXCI. It was softened in seven, 
CCCXII, CCCXLVIII, CCCXCVII, CCCXCVIII, CCCCIV, CCCCIX, 
CCCCXIII. In Case CCCLIV the peritoneum was extensively detached. 
In Cases CCCLXIII, CCCLXIV, it was in a scirrhous condition. In Case 
CCCLXXXV the womb had been long diseased. In Cases CCCLXX, 
CCCLXXI, it was deeply ecchymosed. In Case CCCCXII the walls were 
flabby, and of natural thickness. In Case CCCCXVI there was great deve- 
lopment of muscle. In Cases CCCLV, CCCCII, there was no disease. Of 
twenty-tico of these in which the point is distinctly stated, in nineteen there 
was positive disease, and in three there was no appreciable disease. These 
twenty-two, added to the forty-five previously reported, we have sixty-seven in 
which the condition of the womb happens to be reported. In thirteen 
only is it reported as healthy; in twenty softened; in twenty-one thinned; 
in one both thinned and softened ; in three both thinned and thickened; in 
eight "diseased;" in one thin and brittle. The larger proportion of instances 
in which the condition of the womb is stated, among the cases now presented, 
is probably due to the fact that attention has been only quite recently turned 



185C] 



Trask, Cases of Rupture of the Womb. 



103 



to this point. Observations in this particular are of the highest importance 
in enabling us to determine the causes of this accident, and it is very desirable 
that attention should be especially directed to it in future examinations when 
the result proves fatal. 

The above are, we believe without exception, cases of spontaneous rupture 
of the womb. Lacerations of the cervix and vagina may, of course, take 
place in consequence of rude violence in attempts at delivery, as our cases 
abundantly show. When there is no such morbid condition, if it can be shown, 
as would seem from our statistics to be very probable, that spontaneous rup- 
ture is generally associated with, and we may therefore say due to an appre- 
ciable morbid condition of the womb, the practitioner is relieved of a degree 
of the responsibility which is attached to him. 

In a few cases, not included among" those enumerated, the parts around the 
rupture are described as " deeply ecchymosed others as " flabby f* these 
conditions are most probably due to some decided alteration of structure, 
though there was no appreciable softening or loss of substance. In Case 
GCCCXII, Dr. Cox suggests that the " small extent of the rupture, and the 
fatty appearance of the liver and heart, are worthy of regard, in connection 
with the occurrence of death so soon after so slight a lesion;" we would still 
further suggest that the condition of the uterus, predisposing to rupture, 
might possibly be due in such a case to a fatty degeneration of the muscular 
fibre similar to that found in the heart. This point may be worthy of 
notice in future examinations of those dying from a ruptured womb. What- 
ever the cause may be of the softening and thinning which is found in so 
large a proportion of the cases of this accident in which the condition of the 
womb has been hitherto noted, we certainly, as yet, know little of it. Do 
these lesions take place during the last few months of pregnancy, or do they 
take place during parturition? Some light may yet be thrown upon this 
point by examining the uterus of puerperal females dying from other causes 
than this accident, to ascertain if these lesions ever exist in such. That thin- 
ning of the inferior segment of the womb may occur from long-continued 
pressure of the gravid uterus, we may conceive possible ; but if this be a cause 
of rupture, it is remarkable that the accident is of such rare occurrence, since 
in every pregnant woman the pressure exists. Moreover, we have instances 
in which the thinning was of the body of the womb, and others in which it 
was confined to a limited portion which had become dilated before rupture. 
Thus, in Case CCCLXI, the right side was entire and contracted; the left 
side 11 much distended, very thin, and torn into strips." In Case CCCXIII, 
at the seventh month, the rent was in the fundus, and the surrounding parts 
were of the thickness of writing paper. Of the cases of softening, in 
CCCXLVIII there was evidence of inflammation of some standing. In 
CCCXCVIII, " the parietes were softened, and required no great force to 
produce separation/' Rupture occurred after eight hours' labour, and death 
apparently within one hour after the accident. The changes in the uterine 



104 



Trask, Cases of Rupture of the Womb. 



[July 



structure, it would seem, must have been antecedent to labour, as they could 
scarcely have come on during labour, and certainly not after the accident 
occurred. On the other hand, in Case CGCCIV, in which the pains had been 
feeble, and she died thirty-six hours from the beginning of labour, the organ 
was " very dark, very flabby, and much softened," and yet she is reported as 
strong and healthy, and in her tenth pregnancy. 

These alterations of structure doubtless take place in some instances, ante- 
cedent to labour, from causes not well understood; and in others during 
labour, from long continued muscular exertion 

Contractions of the pelvis have always been prominent among the causes 
enumerated by authors. We have already quoted the remark of Ramsbo- 
tham, that he had never known a case in which there was not some con- 
traction. The most obvious modes by which a contracted pelvis may lead to 
this accident, are the thinning of the lower segment of the womb from 
pressure, and the resistance presented to the progress of the child under the 
impelling power of the uterus. Disproportion between the head and the pel- 
vis, from whatever cause arising, would seem to produce similar results. That 
there is an intimate relation between such disproportions and the occurrence 
of the accident, will appear from what follows. 

In Cases CCCXLIII, CCCXLIV, CCCXLVIII, CCCXLIX, CCCLII, 
CCCLV, CCCLXXVI, CCCLXXXVIII, CCCC1V, CCCCXIV, CCCCXVII, 
total eleven, the pelvis was more or less contracted. These, added to sixty- 
three, make seventy-four as the total of contracted pelves in about four 
hundred cases of rupture. But, as the histories of many of our cases are 
brief and imperfect, the existence of contraction may have been omitted in 
some, so that it is proper to state it thus — that there were at least seventy- 
four in four hundred and seventeen ; or 18 per hundred. 

The head was impacted from disproportion in Cases CCCLVII, CCCCII; 
and in CCCXIY the head was unusually large. There was obliquity of the 
os, the pains being directed against the pubis, in Cases CCCLXXV and 
CCCLXXXIII. In Case CCCCI, the descent was prevented by an enlarged 
ovary. 

In Cases CCCXXXII, CCCXLI, CCCLXXVII, CCCLXXIX, CCCCXIII, 
the foetus was hydrocephalic. These five, added to seven previously reported, 
make twelve, so that there were at least that number of instances of this com- 
plication in about four hundred cases, or three per hundred. 

Rigidity of the os.— In cases CCCXVIII, CCCXXVII,. CCCXXXI only, 
did the obstinate rigidity of the os appear to be the caw.se of rupture; adding 
three previously reported, gives six. 

Obstructing bands in the vagina. — In Cases CCCXXXIX, CCCLXXXI, 
CCCLXXXII, CCCCXIV, the resistance of these apparently caused the rup- 
ture; adding two previously reported, gives six. 

We have, then, as conditions obstructing the progress of the child, and there- 
fore leading to rupture: — 



1856.] 



Trask, Cases of Rupture of the Womb. 



105 



In 417 cases of this accident, at least 74 cases of contracted pelvis. 

" " " 12 " hydrocephalic foetus. 

6 " rigidity of the os. 
" " " " 6 " bands in the vagina. 

1 case of enlarged 'ovary. 

Total, 99 

The proportion of each of these complications, compared with the whole 
number of cases, must be regarded as relatively very large, especially in the 
instance of contracted pelvis. We see that in at least one-fourth of the whole 
number of cases there is a disproportion between the head and the pelvis, or 
an obstruction from organized adhesions of the vagina. This estimate is 
exclusive of cases in which the head is noted as large and firmly ossified. 
We cannot, therefore, err in regarding this relation as one of cause and effect. 
That such obstructions existed in many cases in which it is not alluded to in 
the histories given, is rendered probable by considering the duration of labour 
previous to rupture. 

Tim e from beginning of labour to rupture. — Taking the whole of our cases 
in which this is specified, we find that rupture occurred in — 

6 hours and less from the beginning of labour in 38 cases. 



12 " and over six 
18 " and over twelve 
24 " and over eighteen 
36 " and less 
48 " and less 
Three days and less 
Four days and less 



36 
10 
20 
16 
14 
11 
2 



Comparing these with the duration of labour in the 15,850 cases reported 
by Dr. Collins, we find that 13,412, or eighty per cent., terminated within 
six hours; 1,672, or sixteen per cent., in from six to twelve hours; and that 
in corresponding periods of six hours beyond this, they were but from one 
to two per cent. 

The table above embraces 34 cases of contracted pelvis, but, after deduct- 
ing these, the relative periods remain but little changed. It will be seen 
that the duration of labour previous to rupture is very much greater on the 
average than the entire duration of ordinary labours, according to Dr. Col- 
lins. The obstacle to delivery presented by the disproportion between the 
head and the pelvis, &c, explains this fact; and the probability that such 
hindrances to the progress of the child existed in many of our imperfectly 
reported cases, in which it is not noted, is strengthened by a consideration of 
the protracted character of the labours as a whole. But while the protracted 
character of the labour, under a continued succession of unavailing efforts to 
drive the head of the child through the pelvis, explains the frequent coexistence 
of such disproportion and rupture, there are not a few instances in which the 
duration of the labour was so short, or the character of the labour so little 



106 



Trask, Cases of Rupture of the IVomb. 



[July 



severe, that we cannot so readily trace any necessary connection between 
these and the relative size of the head and pelvis. In not a few instances, 
the first labour-pain was that causing the rupture. Thus, among contracted 
pelves, in Case XLII the head had passed the superior strait at which con- 
traction existed, before rupture took place. In Case XCI, pains were feeble. 
In CCXVIII pains were feeble, and of but six hours' duration. In CLXIX 
pains feeble, and four hours. In CCCXLVIII they were not strong; in 
CCCXLIX, no strong pains; in CLXVI, moderate pains; in CXCVII, 
common labour. 

Inordinate voluntary exertion deserves to be enumerated among the causes 
of rupture. It is prudent to persuade the patient to abstain from voluntary 
efforts, provided there be resistance to the progress of the child from any 
cause. We believe that no case of rupture has yet been published in which 
chloroform 1 was used, which may be due to the fact, that voluntary effort is 
for the most part suspended under its influence. In Case CCCCVIII, Dr. 
iStorer warned his patient of her danger, but the accident occurred. 

Dr. Tyler Smith, in his work on Parturition, p. 225, Amer. edit., remarks, 
" in ordinary labour, some amount of voluntary or instinctive action of the 
muscular system, and particularly of the expiratory muscles, is quite natural 
during the stages of propulsion and expulsion. In acute or severe labour, 
these voluntary exertions are productive of great mischief/' as lacerations of 
the uterus and perineum, and exhaustion. 

Then we have another " class in which rupture was induced by violence, 
or from artificial stimulus of the womb. In Cases LXIII, CXLI, CCXCIV, 
CCCXCIIT, CCCCX, ergot* was given; and in Case CCLXIII, alcoholic 
stimulants. 

Among the cases of hydrocephalus, we have Case CCCXXXII, a labour of 
but two and a half hours ; and Case XLVII, which lasted five hours. The 
remainder of these, with those in which there was rigidity of the os and bands 
in the vagina, were in labour, with scarce an exception, over thirty-six hours. 

Situation of the Rupture. — During pregnancy four involved the fundus; 
these, added to thirteen in the fundus and body, before reported, make seven- 
teen of the fundus and body, and eight involving, more or less, the cervix. 

During labour: Of the entire number of cases, one hundred and ten 
are distinctly spoken of as involving the cervix; seventeen the fundus; 
and seventy-one the body of the womb. Of these seventy-one, by far 
the larger part are reported as ruptures of the anterior or .posterior part, or 
of the right or left side ; and in some of these, it is highly probable that 
the rupture involved the cervix also. 

1 This consideration, which is certainly an inducement to the use of chloroform in 
severe labours, is suggested by our respected friend, Dr. J. P. Batchelder, of New 
York. 

2 Dr. James Fountain, of Peekskill, writes, "I have seen one case only of rupture 
of the womb. It was the elFect of a dose of ergot.'' 



1856 ] 



Trask, Cases of Rupture of the Womb. 



107 



In Cases CCCXLVI, CCCLXXIV, COCCI, CCCCVIII, the peritoneum 
was not involved. 

It appears to be a fair inference, from the above, that labours in which 
rupture occurs are, as a class, protracted ; that the lesions of softening and 
thinning generally precede the rupture, and are, for the most part, a conse- 
quence of the delay ; but that, in a certain proportion of cases, as in those 
occurring during pregnancy and early in labour, these lesions must have 
existed before the expulsive action of the womb was set up j while in certain 
other cases, rupture appears to occur in the womb unaltered by morbid 
changes. 

We copy the table of ages t with the additions, from the new cases : — 



16 years, 


2 patients. 


26 years, 


9 patients. 


37 years, 


8 patients. 


17 " 


1 patient. 


27 " 


5 « 


38 " 


8 «* 


18 " 


1- " 


28 " 


20 " 


39 " 


1 patient. 


19 " 


1 " 


29 " 


3 " 


40 " 


12 patients. 


20 " 


5 patients. 


30 « 


24 " 


42 " 


2 " 


21 " 


3 " 


32 " 


15 " 


43 " 


2 " 


22 " 


1 patient. 


33 « 


6 " 


44 " 


4 " 


23 " 


1 " 


34 " 


4 " 


47 " 


1 patient. 


24 " 


5 patients. 




13 " 


40-45 " 


1 " 


25 " 


11 " 


36 " 


17 " 







The largest number were at the age of 30 years. 

The largest number of cases delivered under Dr. Collins' Supervision, was 
also at the age of 30 years; viz : 2,346 in a total of 16,414 cases. 

The table showing the number of the pregnancy in which the rupture oc- 
curred : — 



No. of pregnancy 
No. of patients 


1st 


2d 


3d 


4th 


5th 


6th 


7th 


8th 


9th 


10th 


11th 


12th 


13th 


Multi- 1 
paras, j 


31 


25 


30 


27 


21 


25 


14 


7 


7 


12 


8 


5 


2 


7^ 



Symptoms of Ruptur* 
labour is stated, is 156. 



— The total, in which the character of the previous 
Of these 



In 46, or 29.5 per cent. 

" 39, or 25 

" 46, or 29.5 " 

" 11, or 7 

" 14, or 9 



it was very severe. 
" strong. 
" moderate. 
" feeble. 

"tedious." 



In fifty-five the pains ceased suddenly ; in seventeen they ceased gradually. 

From this, it appears that liability to rupture is not confined to cases in 
which the labour is of great severity, and that it may sometimes happen when 
the pains from the outset are feeble. Its occurrence in the course of a labour 
of moderate severity, appears to be quite as common as when the pains are 
very severe. We have also the contrast of extensive rupture and escape of 



108 



Trask, Cases of Rupture of the Womb. 



the child with few and feeble pains, and a simple laceration of the muscular 
coat after labour of great severity, as in Case CCCCVITI. 

The sudden cessation of the pains is one of the most characteristic symp- 
toms of the accident; but we learn that this is not of invariable occurrence, 
but that, in a small proportion of cases, the cessation of pains is gradual. 

Again, the recession of the presenting part of the child takes place, as a 
general rule, upon the occurrence of the accident; but the exceptions are 
of sufficiently frequent occurrence to deserve especial notice. Among 
the cases now presented, in CCCXXXIX, CCCLVII, CCCLTX, CCCXCI, 
CCCXCVII, CCCCX, CCCCXIII, CCCCXV, CCCCXVI it is stated that the 
head did not recede ; and among those previously reported, there are several 
of which the same is affirmed. In a few, not included among these, the head 
remained within reach, permitting delivery by the forceps or perforation ; and, 
in a few instances, the head did not recede until the application of the forceps 
was attempted. 

In addition to the instances quoted before, in which the rupture was accom- 
panied by a peculiar sensation experienced by the patient, the same is noted 
in Cases CCCXXIV, CCCXXV, CCCXXXI, CCCXXXII, CCCXXXIV, 
CCCXXXIX, CCCXLI, CCCXLII, CCCLVI, CCCLVIII, CCCLXIIT, 
CCCLXIY, CCCLXVII, CCCLXXXIX, CCCXC, CCCXCV, CCCXCVIIT, 
CCCCI, CCCCII, CCCCIX, CCCCXI, CCCCXYI. 

In CCCXXVI a loud cracking noise was heard, and in Cases CCCXLII, 
CCCLXVII, CCCXCVI the rupture was heard by the patient or bystanders. 

In CCCCXIII, CCCCXV there was no sudden acute pain, or tearing sen- 
sation. In CCCCIII, pains continued once in fifteen minutes, the patient 
crying out at the accession of each, but the womb empty and contracted. 

Exceptions also occur to the early appearance of extreme depression after 
rupture, as is seen, in a remarkable degree, in Cases CCCXXXI, CCCXXXIV, 
CCCLXXXIV, &c. 

While the cessation of the pains, the sudden outcry of the patient, and the 
recession of the child, followed by symptoms of great prostration, in general 
render the diagnosis of the accident easy, the absence of any one of these is, 
as we have seen, not incompatible with the existence of rupture, and the 
knowledge that such exceptions occasionally exist, may, in some cases, aid in 
the diagnosis. 

Influence of Delivery on Mortality. — Total of all cases delivered, 207. Of 
these, 77 recovered, or 37 per cent. 

Total of all cases undelivered, 115. Of these, 27 recovered, or 23.5 per 
cent. 

But among the cases previously reported, were many in which the foetus 
having escaped into the abdomen, was subsequently discharged after decom- 
position, and were reported as remarkable cases of recovery. Among the 
cases now related, of 26 undelivered, only three recovered, or about 11 per cent. 

We repeat what was distinctly stated in our first paper, that these results 



1856.] 



Trask, Cases of Rupture of the Womb. 



109 



are to be regarded only as approximating the relative proportion of cases 
saved and lost in actual practice ; since we would naturally expect to find the 
larger proportion of cases published to have been cases of recovery. 

But, if our statistics did not clearly exhibit a diminished mortality among 
those delivered, they show that life is prolonged by this measure, even in 
cases that do not recover. 

We formerly showed that the average duration of life, after rupture, with 
those delivered, was twenty-two hours; and that of the undelivered, but nine 
hours. By adding to those the new cases, we find that, of those delivered, 
fifty-four per cent, survived beyond twenty-four hours ; while of those dying 
undelivered, twenty-seven per cent, survived beyond the same period. 

Relative success of different modes of Treatment when the Head and the whole 
or part of the Body has escaped into the Peritoneal Cavity. 

SUMMARY OF ALL THE CASES. 

Gastrotomy saved 16, lost 4, or 20 per cent. lost. 
Turning, &c. " 23, " 50, or 68.5 " 
Abandoned " 15, " 44, or 75 

Relative success of different modes of Treatment when the Pelvis is Contracted. 

SUMMARY OF ALL THE CASES. 

" Gastrotomy saved 6, lost 3, or 33 per cent. lost. 
Perforation, &c. saved 15, " 30, or 65 
Abandoned " 0, " 11, or 100 

Adding together these two classes, we get, as the comparative results of the 
different modes of treatment — 

Gastrotomy saved 22, lost 7, or 24 per cent. lost. 

Turning, perforation, &c. saved 38, " 80, or 68 " " 
Abandoned " 15, " 55, or 78 " 

Result as effected by facility or difficulty in Delivery. — Taking all the cases 
together in which this circumstance is alluded to, in seventy cases of recovery, 
forty-eiyht were delivered with ease, or 68.5 per cent. In ninety-one cases 
resulting in death, delivery was accomplished with ease in but thirty-eight, or 
41.7 per cent. 

We have included under easy deliveries those in which gastrotomy was per- 
formed ; the term easy having reference to time occupied, as well as facility 
of execution. In all the cases of gastrotomy in which allusion is made to the 
point, delivery was accomplished very rapidly, and with comparatively little 
suffering. 

If we deduct from each class just enumerated the cases of gastrotomy, we 
still find a preponderance of easy deliveries among recoveries, and of difiicult 
deliveries among those who were lost. Thus, among recoveries, we get 
twenty-six easy, and twenty-two difficult, or 54 per cent, delivered with ease; 
and, among the deaths, thirty-one easy, and fifty-three difficult; or 37 per 
cent, delivered with ease. 

No. LXIIL— July 1856. 8 



110 



Trask, Cases of Rapture of the Womb. 



[July 



Case CCCVIII has not been included in the enumeration of cases of gas- 
trotomy, as the operation was peformed several weeks after the accident. 

We have already discussed at some extent, in the former part of this paper, 
pp. 411, 412 (April 1848), the conditions under which gastrotomy commends 
itself as the proper resource. It is evident, we think, that this operation is now 
regarded with more favour by the profession than formerly; at least five cases 
having met our eye as reported within the last five or six years. These addi- 
tional cases, in connection with those delivered by other methods, confirm in 
every respect the conclusions to which we arrived, after a study of the cases 
embodied in our first paper. Those conclusions were briefly as follows : — 

1. When rupture occurs, where there is no disproportion between the pel- 
vis and the head of the child, and the head remains in the cavity of the 
pelvis, the child being ascertained to be living, the careful employment of the 
forceps should be attempted; if the head retreat, perforation will probably be 
required; if the child is dead, perforation is to be preferred. An impaction 
of the head in the hollow of the pelvis would of course require the use of the 
perforator. 

2. Should the foetus have escaped into the peritoneal cavity, the feet may 
be sought, and the child delivered by turning, provided there be a pelvis be- 
yond doubt ample, a head of moderate dimensions, and the edges of the uterus 
uncontracted, or the rent confined chiefly to the vagina. 

3. But as contraction of the uterus almost uniformly takes place upon the 
escape of the child, it will prove an obstacle to delivery in almost every case 
of escape of the child, in which the vagina is not also involved to a very con- 
siderable degree. The performance of gastrotomy will then offer the best 
chance of success. 

We believe that a neglect of this mode of delivery has contributed much 
to the exaggerated estimates of the mortality of the accident, which are so 
generally entertained. It is an operation requiring no little resolution and 
true courage under the trying circumstances in which the physician is placed, 
and consequently arises the need of settled principles of practice to guide one 
in this extremity. 

Although, as we have distinctly repeated, we do not believe that our cases 
give the actual proportions of recoveries and deaths under any one course of 
management, yet we maintain that the principal circumstance which vitiates 
one class is the same that renders the remainder imperfect, viz : an undue 
proportion of recoveries ; and inasmuch as we have shown, that, in some re- 
spects, our statistics conform with the experience of -standard authorities, and 
that in others they conform with acknowledged principles of general practice, 
we have confidence that they are worthy of a degree of reliance in elucidating 
points upon which we have no other standard wherewith to compare them. 
The relative success of gastrotomy is, as we have seen, greater than that of 
any other mode of delivery, and we believe that a more frequent resort to it 
would result in a diminished mortality to the accident. In short, as a gene- 



1856.] Brinton, Relations of Right Spermatic Vein to Varicocele. Ill 



ral rule, from whatever cause we might he led to anticipate a protracted and 
difficult delivery by the natural passages, gastrotomy mill afford the best chance 
of recovery. The only exception we would make is, when there is impaction 
of the head in the pelvic cavity or in the inferior strait. 

There is a total of twenty-four cases of hernia of the intestine through the 
rent in the womb. In Case CCCLXIV, it was of the epiploon. In Case 
CCCLXXXII, death was attributed to the strangulation of the bowel. 

In one instance, the placenta only disappeared through the rent. 

In Cases CCCXLVI, CCCLXXIV, CCCCI, CCCCVIII, the peritoneum 
was not involved. 

Case CCCLXI was complicated by presentation of the placenta. 

In Cases CCCXCVI, CCCXCIX, rupture occurred in wombs previously 
ruptured. 

Several instances of injudicious interference, or unjustifiable violence in 
delivery, will be observed on a careful perusal of the cases. 

Case CCCXLVII is an instance of spontaneous evolution; the head which 
had presented, retreating, and the feet descending within reach. Dr. Kams- 
botham has observed this evolution. 

In Cases CCCLXY, CCCLXVI, the womb was pierced by the foot of the 
child. In Case CCCLI it was pierced by the fingers of the midwife. In 
Case CCCLVI, rupture occurred from a fall weeks before labour came on. 



Art. IV. Description of a Valve at the Termination of the Right Spermatic 
Vein in the Vena Cava, with Remarks on its Relations to Varicocele. By 
John H. Brinton, M. D. (With a plate.) 

The pathology of the venous system has of late years been carefully inves- 
tigated by numerous and accurate observers ; and although by their efforts 
much light has been shed upon subjects hitherto imperfectly comprehended, 
there still remains much to be explained in this important class of affections. 

Of all the lesions to which the veins are subject, none perhaps has attracted 
more attention than phlebectasis or varix. In this condition the vein is said 
to be varicose, its walls become unnaturally dilated, and its calibre conse- 
quently increased. The veins most frequently affected are those of the 
rectum, the spermatic cord, and the inferior extremity, although doubtless 
every portion of the venous system is liable, under certain circumstances, to 
become the seat of varicose dilatation. 

The causes of the varicose condition of the veins are various, and are as yet 
not fully elucidated. The older surgeons were in the habit of invoking, as 
the sole cause, the existence of simple mechanical impediment to the return 



112 Brinton, Relations of Right Spermatic Vein to Varicocele. [July 

of the venous blood ; but more recent observation has shown that explana- 
tions other than of a purely mechanical nature must be sought for. 

That pressure upon a vein — the existence of tumours — the weight of a 
gravid uterus — the presence of a ligature — or a position of the body, by which 
the current of venous blood is directed contrary to gravitation — may all act 
in producing varix, is incontestable. Cases, however, constantly occur in 
which it is evident that none of these predisposing circumstances exist ; and 
on these grounds, therefore, the' explanation is impossible. 

Hasse, in his treatise on general pathology, 1 advocates the doctrine that 
the varicosities of the veins are due to " a peculiar habit of the body, a mor- 
bid predominance of the venous system, which manifests itself through the 
intervention of influences at once mechanical and dynamical." 

Rokitansky 2 also seems disposed to teach that the doctrines which ascribe 
the origin of phlebectasis to mechanical obstruction alone are untenable; for, 
he states, that " we have, therefore, after much experience, adduced other 
causes in explanation of the dilatation of the veins. There are, however, 
always cases occurring in which these cannot be detected; and as varicose 
veins present many symptoms which are hitherto perfectly unexplained, the 
theory of phlebectasis is still deficient in an important part." 

It has been affirmed, and is generally supposed, that the superficial veins 
alone are subject to a varicose enlargement. Sir Benjamin Brodie, 3 in his 
Clinical Lecture on Varicose Veins of the Leg, explains the fact by stating 
that the deep-seated veins are exposed to uniform pressure on every side by 
the surrounding muscles, which is sufficient to prevent their dilatation. Re- 
cently, however, M. Verneuil read before the Academy of Medicine at Paris 
a paper, in which he contends that whenever varicose veins occur spontane- 
ously on the lower limbs, the deep-seated veins are also affected; and also, 
that the deep muscular veins may be dilated without the superficial veins being 
in any way involved. These results, should they be verified by future observa- 
tions, would doubtless go to weaken the explanation of the occurrence of the 
affection, as the result of purely local accidental causes. 

The views already expressed with regard to the general causes of varix, 
apply with especial force to the dilatation of the veins of the spermatic cord, 
constituting varicocele or circocele. 

This affection is generally met with, according to the statistics of Landouzy 
and Curling, about the period of puberty, and is of far more common occur- 
rence than is generally supposed. 

An interesting point with regard to the etiology of varicocele is this : Has 
the affection any direct relation to the varices of the veins; and does it 
occur synchronously with them in the same patient? Mr. Curling states that 
in patients suffering under varicocele, he has often found weakness in other 

1 Sydenham edition, p. 37. 

2 Rokitansky's Pathological Anatomy (Sydenham), p. 366. 

3 Brodie's Clinical Lectures on Surgery, Amer. ed., p. 113. 



1856.] Brinton, Relations of Right Spermatic Vein to Varicocele. 113 

portions of the venous system, especially of the inferior extremity. Hasse, 
on the contrary, is inclined to consider that whenever one form of varix 
occurs, it is to the exclusion of all others. 

The occurrence of varicocele is insidious and gradual, and is productive at 
first of little or no inconvenience. In fact, the patient is unaware of the 
existence of the disease until some time subsequent to its development. When 
discovered, the swelling in the scrotum resembles, as has been well said, a 
bundle of earthworms, of greater or less size ; but it must be observed that 
the size of the mass is by no means an indication of the inconvenience sus- 
tained by the patient. A large varicocele will often give rise to but little 
pain ; whilst one of small size may sometimes be attended with very great 
suffering. 

The disease once developed, the changes which take place both within and 
without the walls of the vein, are exactly similar to those observed in every 
instance of phlebectasis. The vein, besides being increased in calibre, becomes 
tortuous, and increases in length; its walls at first somewhat thinned, become 
eventually thickened and hypertrophied, and insufficiency of the existing 
valves follows. 

A most striking peculiarity with regard to this disease is the frequency of 
its occurrence upon the left side of the body, and its very great rarity upon 
the right. This circumstance, although it has attracted the attention of every 
observer, has never as yet been satisfactorily accounted for. The fact, how- 
ever, is incontestable, and in explanation the following reasons have beea 
adduced. 

1. The difference in the direction of the venous current through the sper- 
matic veins upon the two sides of the body. It is asserted that, as the sper- 
matic vein of the right side empties into the vena cava, in a direction nearly 
parallel with the course of the blood in this latter vein, no impediment is 
offered to the discharge of its contents. Upon the left side, however, the 
anatomical relations of the veins vary. Here the spermatic vein throws its 
blood into the emulgent vein in, as we are told, a nearly perpendicular direc- 
tion ; and the renal vein then empties itself into the vena cava in a similar 
manner. Hence it is supposed that the course of the blood through this 
double rectangular channel is sufficiently impeded to give rise to the disease 
in question. 

2. The pressure of the viscera upon the left renal vein as it passes across 
and rests upon the aorta. 

3. The position of the testis, which hangs lower upon the left than upon 
the right side. 

4. The pressure of the sigmoid flexure of the colon, especially when charged 
with accumulated feces, upon the spermatic veins. 

A careful study of the anatomy of the veins in question will, however, I 
think, clearly show that the frequent occurrence of varicocele upon the left 
side, and its non-occurrence upon the right, is not in reality due to the causes 



114 Brinton, Relations of Right Spermatic Vein to Varicocele. [July 



ordinarily assigned ; indeed, the reasons before alluded to have already been 
discarded by a most accurate observer, Nelaton. 1 Sir Astley Cooper, in his 
remarks on this disease, also conveys an idea of the insufficiency of the pre- 
viously quoted causes of varicocele. 2 

Desirous of investigating this subject more fully, I have, during the past 
year, made a series of examinations upon the dead body, and with the follow- 
ing deductions : — 

1. That the causes hitherto assigned are insufficient to account for the rare 
occurrence of varicocele upon the right side. 

2. That the cause of the non-occurrence of varicocele upon the right side 
is referable to the existence of a very perfect valve hitherto unnoticed, at the 
termination of the right spermatic vein in the vena cava. 

3. That no such valve exists upon the left side at the termination of the 
spermatic in the emulgent vein. 

4. That a similar valve exists in the analogous vein of the female, the right 
ovarian vein, but none upon the left side. 

The examination of this valve may be best conducted in the following 
manner : Remove the vena cava, emulgent, and spermatic veins from the 
body ; pin them upon a board, in position, and then lay open the vena cava 
anteriorly by a longitudinal incision. Pass a probe gently up the right sper- 
matic vein, and it will then be found to emerge into the vena cava through a 

slit-like aperture, not corresponding in size 
or direction with the apparent opening of 
the spermatic vein, as viewed from the in- 
terior of the vena cava. This apparent 
orifice is in reality a large, deep, and very 
perfect sinus, across which the delicate trans- 
parent valve floats. This sinus serves to 
receive regurgitating blood, and thus effect- 
ually to close the valve. The presence of 
this valve may be also demonstrated by an 
injection thrown up the vena cava; the in- 
jected matter will pass freely into the left 
spermatic vein, but not into the right; 
unless an undue amount of force be exerted, 
and the valve thus forced. The length of 
the valve, measured upon its free border, is 
c. venacara. about the one-fifth of an inch. Microsco- 

r. Right spermatic Tein . . . 

a. Aperture between right spermatic vein pically examined, it proves to be formed by 
and vena cava. a prolongation forwards of the internal and 

v. Right spermatic valve. . . „ . . 3 

Si Sinus> middle tunics ol the spermatic veins, and 




1 Nelaton's Clinical Lectures on Surgery. Atlee, p. 644. 

2 Testis, p. 231, Amer. edit. 



1856.] Brinton, Relations of Right Spermatic Vein to Varicocele. 115 

is composed chiefly of elastic and connective tissues. The former is arranged 
in thick, wavy, longitudinal bands, crossed here and there by transverse 
striae of the same structure. These transverse bands are more developed 
towards the free margin of the valve. The connective tissue is also arranged 
so as to form thick fibrous bands. The surface of the valve is lined by the 
ordinary epithelium found in the interior of the veins. Examination of the 
left spermatic vein has not revealed, as far as my experience goes, the exist- 
ence of a similar valve. 

I am not aware that the attention of anatomists or of pathologists has ever 
been called to the existence of the valve. Yalves have, it is true, been said 
to exist in the spermatic veins, but they have always been described as occur- 
ring below the abdominal rings. In most works on anatomy no allusion is 
made to them whatever. 

In the anatomical plates of Fabricius, published at Leipsic, in 1687, no 
spermatic valves are described, although the plates of the venous system are 
full and for the most part accurate. Cheselden also fails to notice them. 

Morgagni, in his description of varicocele, merely observes that the disease 
is more frequent upon the left than upon the right side. This he attributes 
to the angle formed by the left spermatic vein. {Be Sedibus et Caus. Morb.j 
Epist. 43, Art. 34.) The Elder Monroe, in his remarks upon the anatomy 
of the spermatic vessels and cord, and in his article " Varicocele," denies the 
existence of valves in the spermatic veins. 1 

In the posthumous works of Petit, vol. ii. p. 498, varicocele is described at 
length, and the following passage as to the causes occurs: "Ex vitus hepatis 

frequentiores esse in latere sinistro, quod faeces in colo sinistro 

morentur." Jourdan 2 denies the existence of valves, but mentions that Monroe 
pretends to have found them. 

In Fyfe's Anatomy, Edin., 1810, the spermatic vein is described as furnished 
with valves, but more particularly without the abdomen. 

Sir Astley Cooper 3 states that the veins of the cord below the external ring 
have valves, but that owing to their anastomoses they may be injected con- 
trary to the course of the blood. 

In Quain's plates, vol. ii., the same remark is made concerning the exist- 
ence of the valves below the abdominal ring. 

Mr. Curling 4 describes the spermatic veins thus: "Many anatomists speak 
of the spermatic veins as being destitute of valves, which they assign as one 
of the reasons for the occurrence of varicocele. I have several times injected 
these veins with alcohol, and, on laying them open, have observed valves in 

1 The -works of Alex. Monroe, M. D., published by his son, Alex. Monroe, M. D., 
Ed. 1781, pp. 542 and 582. 

2 Encyclopoedie Anatomique, tome iii. p. 646. 

3 Testis, Amer. edit., p. 38. 

4 Diseases of Testis, London, 1843, p. 28. 



116 Brinton, Relations of Right Spermatic Vein to Varicocele. [July 

the large vessels, and I have also found injections thrown into the veins 
arrested by the valves. They are seldom, however, seen very near the testis, 
or in the smaller veins, forming the plexus ; nor have I observed them within 
the abdomen." 

Jamain, 1 in his anatomy, describes the veins, and assigns as the cause of 
varicocele on the left side, the angular direction of the current of blood. 

Sappey 2 speaks thus minutely of the course of the spermatic veins: " En 
penetrant dans l'abdomen les veines du testicule sont le plus souvent reduites 
a deux troncs, qui cheminent entre le peritoine et le fascia iliaca ; celles du 
cote gauche passent sous l'Siliaque du colon, dont le poids les comprime, et 
explique au moins en partie le siege presque constant du varicocele a gauche." 

Professor Hyrtl, of Vienna, 3 describes the spermatic veins as "valveless" 
(Jdappenlosen), and attributes the development of circocele to the length and 
great calibre of the veins, and to the fact of their being destitute of valves. 
In the several treatises on anatomy by' Wistar, Wilson, Knox, and Sharpey and 
Quain, 1 find no mention of the valve I have described at length ; nor is the 
existence of any such arrangement alluded to in the recent treatises on surgery 
by Chelius, Fergusson, Pirrie, or Erichsen. 

Hasse 4 ascribes varicocele of the left side to the causes previously stated, 
and also "to the general practice of carrying the scrotum upon the left side, 
whereby the left testicle and spermatic cord are obviously more compressed 
than the right, and at the same time exposed to a degree of warmth favourable 
to the production of the evil." 

In the pathological anatomy of Drs. Jones and Sieveking, the usual circum- 
stances are assigned as the causes of varicocele upon the left side in preference 
to the right. In an article on the diseases of the veins, 5 Mr. S. J. A. Salter 
is even more specific in the description of the anatomy of the spermatic 
veins; for after the usual enumeration of the proximate and dynamical causes 
of varicocele, he adds : " It cannot be said that there is any difference in 
structure or constitution between the two veins in the same individual." 

From the careful examination of works of the above mentioned authors, and 
of others, I feel convinced that the presence of the spermatic valve of the right 
side has hitherto escaped the attention of observers; a circumstance somewhat 
singular when we consider the peculiar pathological fact presented in the vari- 
cose condition of the left side. I am also inclined to believe that a careful 
consideration of the import of the right spermatic valve may tend to place the 
pathology of varicocele before us in a new point of view.. Hitherto writers 
upon the subject have been in the habit of considering varicocele as an affec- 
tion of the left side of the body, produced by local causes peculiar to that 

1 Paris, 1853, p. 442. 

2 Traits d'Anatomie Descriptive, tome ler, p. 566. 

3 Handbuch der Topographischen Anatomie, Wien, 1847, Bd. 2, p. 42. 

4 Hasse, loc. ext., p. 45. 

5 Todd's Cyclopsedia of Anatomy and Physiology, vol. iv. p. 1397. 



1856.] Brinton ; Rela tions of Right Spermatic Vein to Varicocele. 117 

region alone, and not existing upon the other side. That such, however, is 
not the case will be evident if each of the hitherto received causes of varico- 
cele be examined in detail. 

In the first place, does the perpendicular direction of the venous current 
upon the left side, in reality, act in producing the disease ? In regard to 
this M. Nelaton states, that he has made many dissections for the purpose of 
examining the direction of the spermatic veins, and that rarely did he find 
"the vein emptying perpendicularly; that the spermatic veins curved, so that 
the blood in both veins, the spermatic and renal, had nearly a parallel direc- 
tion before joining." This observation I have had frequent opportunities of 
verifying by dissection ; and the fact is, moreover, in analogy with the termi- 
nation of the other veins of the body. 

2d. Are the spermatic veins liable to compression by the sigmoid flexure 
of the colon ? Such a view is at least rendered improbable when we examine 
the exact position of the spermatic vessels in the abdomen. We here find 
them placed behind the peritoneum, and securely invested by a fibrous sheath. 
This involucrum has been described at length by the elder Monroe, who 
even assigns to it the office of protecting the subjacent vessels from the pres- 
sure of the viscera. The high authority of Nelaton can also be adduced upon 
this point. This latter observer denies the influence of such pressure in pro- 
ducing varicocele ; and he states, moreover, that the dilatation of the vein 
continues high up the abdomen. A specimen of a dilated ovarian vein of the 
left side, now in my possession, substantiates the truth of this assertion ; the 
varicosity extending up to the emulgent vein. In this preparation, the valve 
which I have described exists upon the right side, which is unaffected. 

That the accumulation of feces in the colon does not act as a predisposing 
cause to varicocele, will be rendered evident when we reflect for a moment 
upon the epochs of life in which these different states exist. Varicocele is a 
disease almost peculiar to puberty, whilst constipation occurs as a rule at a 
later period of life. In all instances I have failed, upon inquiry, to trace any 
clinical connection between the affection under consideration and the accumu- 
lation of feces which has been assigned as its cause. 

3d. The position of the testis — lower upon the left than upon the right 
side — certainly cannot play a very prominent part in the production of the 
disease. The greatest difference in the length is not more than half an inch. 
In this connection it may be observed, that whilst the ovarian veins are 
of precisely the same length, the left one is always the seat of the varicose 
dilatation. 

From the consideration of the foregoing facts it seems probable that the 
causes of varicocele hitherto adduced are insufficient to account for the pre- 
sence of the disease. May we not, with at least equal justice, believe, that 
the causes of the affection are more general than is commonly imagined ; and 
that in reality the dilatation of the spermatic veins is simply a symptom of 
engorgement of the great internal venous trunks? It will then be easily 



118 



Porter, Case of Spinal Apoplexy. 



[July 



understood what influence may be exerted by the right spermatic valve in 
preventing the development of the disease upon that side ; and may not the 
same law obtain, in the explanation of varix of the left ovarian vein, since 
we have in the female an analogous locality to the valve? 

EXPLANATION OF PLATE. 

Dissection of the vena cava, emulgent, and spermatic veins, showing the right 
spermatic valve, and its accompanying sinus. 
c. Vena cava. 

e. Emulgent vein. 

r. Right spermatic vein. 
I. Left spermatic vein. 

a. Aperture by which the right spermatic vein empties into the vena cava. 

v. Right spermatic valve. 

s. Sinus, across which the valve is stretched. 

f. Termination of the left spermatic vein, in the emulgent vein B 



Art. V. — Case of Spinal Apoplexy. By Isaac Gr. Porter, M. D., of 

New London, Conn. 

So rarely do we meet with cases of this nature, or even of spinal congestion 
terminating fatally, that the following example, though deficient in some of 
its details, may be interesting. 

" Spontaneous effusion of blood into the cervical, dorsal, or lumbar por- 
tions of the cord, is an occurrence of extreme rarity, and its history is, con- 
sequently, very defective. The cases recorded by Abercrombie, Chevalier, 
Stroud, Cruveilhier, and others, show that the attack is always characterized 
by acute and sudden pain in the back, corresponding with the seat of the 
effusion. Sometimes there are precursory symptoms of shivering, and in 
others there is sudden paralysis of one or more of the lower extremities, 
below the seat of pain. The other symptoms that have been observed are 
similar to those we have noticed while treating of myelitis, affecting the cer- 
vical, dorsal, or lumbar portion of the cord." — Tweedie's Lib. of Med., vol. 
ii. p. 324. 

In 386 recorded cases of apoplexy, Andral notices the effusion as occurring 
eight times within the spinal canal. 

A talented and opulent merchant, largely engaged in commerce, was busily 
engaged from early dawn until afternoon of an intensely hot day in Septem- 
ber last, in getting to sea one of his ships. He was forty years of age, and 
his general health good, although there is in the family a proclivity to ple- 
thoric, congestive, and paralytic diseases. He had drank freely, though pru- 
dently, of cold liquids, and, after the ship had sailed, went into a barber's 



Am. Jour. Med. Set., vol. xxxii. N. S. 



P L A T E 




Dissection of the vena cava, emulgent and spermatic ireinS, 
showing the right spermatic valve. 



e 



1856.] 



Porter, Case of Spinal Apoplexy. 



119 



shop about 5 o'clock P. M., and had his head "shampooed," as he had occa- 
sionally done before. Heated and exhausted as he was, the irrigation of the 
water, as it flowed over the back of his head and neck, was, for a time, very 
grateful, though it had been standing, as was said, the most of the day in the 
room. He soon, however, became chilly, and was seized with a violent pain 
in the lower part of his back, and, on attempting to leave the shop, became 
partially paralyzed ; and he was obliged, soon after, to stand motionless in 
the street for some minutes. The powerlessness then seemed gradually to 
leave him, and he was able to walk, though with difficulty, his gait being 
noticeably changed, as observed by his friends. About half an hour after, 
he was again seized with pain in the back and numbness, and loss of power 
in the lower limbs, attended with a very severe chill ; yet the palsy was not 
severe enough to prevent his walking home at 6 P. M., when he went imme- 
diately to bed. By advice of friends, he took hot stimulant drinks and teas, 
hot pediluvia, and had bottles of hot water placed around him. He soon 
emerged from the chill, and moderate reaction came on, but complained 
greatly of pain in the back, and numbness of his extremities. A little before 

10 o'clock P.M. I saw him — intellect perfect; countenance anxious, though 
disposed to think lightly of his disease, saying he should be at his store in 
the morning; shaking with the cold at the slightest motion of the bedclothes; 
gentle perspiration, but the hands cold and clammy when exposed to the air. 
The pain in the back, and numbness, still continued, and new distress, like 
colic, had lately manifested itself in the abdomen, with a most urgent desire 
for a passage from the bowels. A free motion had occurred just before the 
attack, and, previous to my arrival, he had endeavoured to use the close-stool, 
but immediately on rising, with help, into the upright position, he had fainted. 
Insisting on making a second attempt, he arose with help, but rather fell than 
sat in the chair. Immediately his head dropped on his chest, his breathing 
became stertorous, and the muscles began to show convulsive action. Con- 
trary to my express command, he afterwards made another attempt, with the 
same result, and on coming to himself he said: U I am truly in a critical 
situation, and will make no further effort." There was desire to pass water, 
but it was by no means so urgent, and none passed him during life. From 

11 o'clock P. M. of Tuesday night until 4 P. M. of the following day, when 
he expired, he maintained the horizontal position, except as he vomited twice 
in the night, and slightly turned from side to side, with restlessness and jac- 
titation from pain in the bowels and back. His pulse, as I entered the room, 
was a mere thread, contrasting strongly with his flushed and congested coun- 
tenance. The slightest pressure annihilated it, and after effort on his part 
it was entirely gone. 

The aspect of the case, at the outset, was almost hopeless, and the symp- 
toms progressed with rapid strides towards a fatal termination. About 
4 o'clock in the morning his acute distress left him ; the pulse slightly rose 
in volume and power under the use of stimulants and nourishment, and by 
crowding them it was for a short time maintained, but soon either the sto- 
mach rejected them, or they ceased to have anything more than a momentary 
influence. He soon after became somnolent, though he was aroused without 
difficulty until within an hour or two of his death, and always showed a good 
share of intelligence, and answered questions promptly and properly. While 
apparently asleep, he occasionally uttered incoherent expressions, but on 
being aroused, was perfectly conscious. Showing how naturally and sponta- 
neously our thoughts flow in their accustomed channels, shortly before he 
expired he said in a firm voice, " I believe that everything is aboard," which 
were his last words. "Even in our ashes, live their wonted fires." 



120 



Porter, Case of Spinal Apoplexy. 



[July 



Soon after dissolution, remarkable evidence of venous engorgement pre- 
sented itself. The entire surface of the body appeared as if deeply ecchy- 
mosed or cyanosed. The colour was uniform and permanent. 

There were unusual reasons for preserving the body as long as possible, 
and the weather was very hot and oppressive. Much as a post-mortem 
examination was desired, yet these reasons, and the mechanical difficulties to 
be overcome being so great in exposing the vertebral canal, and the want of 
suitable instruments, all conspired to render it impracticable. 

The treatment in this case was directed, at the outset, to obviating the 
alarming prostration. Ignorant, at that time, of the cold douche, the chills 
in the barber's shop, and the subsequent loss of muscular power, the debility 
was referred to some unknown functional derangement, and alcoholic drinks, 
sulph. ether, and aromat. spts. ammo, were freely used with animal broths; 
and externally, fomentations were applied to the abdomen, and Granville's 
lotion, sinapisms, and a blister to the back. Leeches were proposed to the 
medical gentlemen in consultation, but declined on account of the adynamia. 
The influence of medication was momentary and trifling. 

This case, so rapid in its progress towards dissolution, possesses some pecu- 
liarities which may repay examination. Deprived, as we are, of the positive 
testimony of a post-mortem examination, we are compelled to examine it per 
vias exclusionis, and much in the same way as if the patient, after having 
been exceedingly ill, had finally recovered. Was it, then, a case of cerebral 
congestion, or apoplexy ? This latter supposition must be excluded by the 
existence and continuance of consciousness and intellect until just before 
death. "Was it a case of acute myelitis? The symptoms, in some respect, 
pointed to that affection, but the attack was much more sudden and violent 
than is usual in that disease, and the termination more speedy — myelitis 
proving fatal, usually, from the fifth to the tenth day; and, at no time, were 
symptoms of active inflammation present. Spinal meningitis is also excluded 
by the absence of tonic rigidity and increased sensibility, which characterize 
that affection. 

Was it a case of simple venous engorgement of the medulla spinalis? or 
was this state accompanied or succeeded by serous or sanguineous effusion 
within the canal? The leading symptoms, at the outset, were pain in the 
back, and paralysis of the lower extremities. These conditions, however, dis- 
appeared after a few minutes, so that the patient was able to walk home. 
Had effusion occurred at the first appearance of these symptoms, it is not pos- 
sible that the pressure on the medulla spinalis could have been so speedily 
removed as to have allowed the use of his limbs. But the symptoms returned 
with renewed violence, and proceeded uninterruptedly to a fatal termination 
by an apparent extension of an effusion (which then first occurred) upward 
toward the brain. The severe colic pains in the abdomen will be remem- 
bered. These are very common in myelitis of the lumbar portions of the 
cord, and according to Tweedie, also occur in spinal apoplexy. In the up- 
ward progress of the paralysis, the cardiac and pulmonary nerves were finally 
involved. The powers of the circulation, however, were easily affected, 



1856.] 



Porter, Case of Spinal Apoplexy. 



121 



doubtless through sympathy, and the violence of the nervous shock. It is, 
therefore, my opinion, that so intense became the congestion in the last attack, 
that it resulted in a gradual effusion into the spinal canal. 1 " When the 
symptoms come on slowly, and in an imperfect degree, without anything like 
a sudden shock, or fit, the effusion is generally of serum." (Cyc. Heel., art. 
Cerebral Apoplexy.) It may have been serous, but from the intense engorge- 
ment of the surface of the body immediately after death, and which was doubt- 
less to be attributed, in part, to rupture of the capillaries, we have reason to 
believe from the condition of the bloodvessels, as thus evinced, that it was 
sanguineous. 

It is a question of some interest, how far the cold douche, on the base of 
the brain, exerted a noxious influence. The power over the circulation of 
the blood, by the application of heat and cold, is shown by the influence of 
sinapised foot-bath, and the cold douche, or the ice-cap to the head in con- 
gestive headache, threatening apoplexy, or in convulsions, with strong deter- 
mination of blood to the head. The objection may be offered, that granting 
a remedial influence in this case, it does not prove the converse, viz : that the 
same agent may operate at one time as a cure, and at another as a cause, of a 
similar affection. Another instance, then, more in point, may be adduced. 
The very injurious effects on the organism of currents of cold air operating 
on limited portions of the surface, will not be denied — nor the pernicious in- 
fluence of wet feet on an individual not inured to it by habit, more especially 
if he be fatigued at the time, and constitutionally infirm. This is probably 
owing, primarily, to a depressing influence thus exerted on the " automatic 
nerve force," which, succeeded by irregular circulation in the capillaries, 
finally results in internal congestions. 

Todd, however, in his late valuable work on diseases of the nervous system, 
has the following words : " It is unsatisfactory in a scientific, and dangerous 
in a practical point of view, to refer paralysis to local congestion. The ves- 
sels of a part, all important as they are to its nutritive and other vital actions, 
are nevertheless only secondary elements in the condition of the organ, and 
unless in themselves diseases, they can play only a secondary part in the pro- 
duction of organic or functional derangement. Congestion of bloodvessels, 
or hyperemia of a part, must be an effect either of some disordered state of 
the intrinsic elements of the tissue or of the blood, or of the forces by which 
the blood circulates." These are doubtless correct pathological principles, 
and two of the conditions specified I think we have in the foregoing case — 
" the disordered condition of the bloodvessels, and of the forces by which the 
blood circulates." In ordinary health, the cold douche, even when operating 
on the base of the brain, may have been harmless, but not so when the vital 
energies were at a low ebb, through a long and exhausting day's exertion in 
a hot sun. It is under similar circumstances that a draught of cold water 



1 See a case recorded by Walsh, Lancet, July, 1849, p. 7. 



122 



McSherry, Obstetrical Memoranda. 



[July 



sometimes proves fatal. The same thing is shown by a fact familiar to 
" gentlemen of the turf/' A horse, although quite warm from exercise in 
the early part of the day, may drink cold water with comparative impunity, 
while one-half the amount, if drank at the close of a summer day's travel, 
would cause his death. 

Having thus shown that the forces by which the blood circulates were dis- 
ordered and enfeebled, as a part of a general affection, a few words only re- 
main in relation to the condition of the bloodvessels. That they were in a 
morbid state appears from the aspect of the surface of the body immediately 
after death. Should this be referred to incipient decomposition, the question 
arises, why does not the same appearance always occur in early decomposi- 
tion ? The innervation and nutrition of the capillaries were doubtless affected 
at the same time that the congestion occurred in the medulla spinalis, of 
which softening of these vessels, and ultimate effusion, were the consequence. 



Art. VI. — Obstetrical Memoranda. By Richard McSherry, M. D., of 

Baltimore. 

Labours Complicated by Accidental Shortening of the Cord. — Death of the 
Child from an unusual cause. — During the past year I attended several cases 
of labour, protracted for hours after the child's head had reached the peri- 
neum, when there was no manifest cause of delay either in the size of the 
head, or in the condition of the mother. In every case the delay was owing 
to accidental shortening of the cord. In two cases the children died before 
delivery, of strangulation, from double folds of the cord closely investing the 
neck. In another case the cause of death was different, and very uncommon. 

On the 18th of Sept. I was called to Mrs. H., rather a delicate young woman 
in labour with her first child. I found her suffering pretty severely, and 
vomiting freely of mucus and greenish bile ; she told me she had been long 
very costive, troubled with headache and general malaise. In a reasonable 
time the head began to distend the perineum, the soft parts were relaxed, 
and the pains were sufficiently active. I promised her a speedy termination 
of her sufferings, but finding pain after pain fruitless, little gained by each 
pain and that little lost directly after, I determined to use the forceps. At 
the expiration of two hours, however, from the time when I first expected each 
pain to bring the head, it came into the world unassisted, with a single turn 
of the cord around the shoulders. No effort was required to disengage it; 
the body followed immediately. Upon looking at the child I observed a 
large bluish mass overlying the abdomen, which upon examination proved 
to be the intestines deeply congested. By careful tracing I found they had 
escaped by a rent at the side of the umbilical cord. They were much dis- 
tended with meconium, but after some patient manipulation I succeeded in 
restoring them within the abdominal cavity. Compresses and bands were 
applied immediately to the tumid abdomen ; the child lived feebly for half 



1856.] 



McSherry, Obstetrical Memoranda. 



123 



an hour, when it expired. The contents of the stomach issued from the 
mouth in a thick stream. 

In the other two fatal cases the expulsion of the shoulders was retarded by 
the turns of the cord ; I found it impracticable to disengage them without 
violence, and resorted to the scissors, by which the labour was expedited 
though the children were lost. 

The instructions of authors are uncertain and contradictory in such cases ; 
the use of the forceps is commonly advised, but if I had resorted to the 
instrument in the case of the rupture at the umbilicus, the friends would 
have thought the operation the cause of death, and indeed, the same suspicion 
may have fixed itself upon my own mind. 

Other cases terminated favourably. 

Considering the difficulties of treatment, it appears to me that the practi- 
tioner does best who confines his active assistance before the birth of the 
head to keeping the fundus of the womb depressed, and to supporting the 
perineum. Caseaux says, "If the head be at the inferior strait, at the 
time when the alternate movements of elevation and descent begin to mani- 
fest themselves during and after the contraction, the forceps should be 
applied." (See his treatment of Dystocia, from shortness of the cord.) Bon- 
net says, in his Cours d' Accouchement, "II est difficile de suivie un traitement 
qui met Jin & un tel etat." So I have found it. He continues, "cependant, 
si on parvient a le reconnaitre, et si Taccouchement en est empeche, il faut 
couper le cordon, et le lier, sil est accessible aux doigts, on tout au moins, 
aussitot que 1' enfant sera sorti des organes maternels." A single turn of the 
cord may be relaxed by the application of the accoucheur's fingers drawing 
upon the placental extremity, when sufficiently in reach, but a double turn is 
unmanageable, and slipping it over the head is often quite impracticable. 
The scissors then must be our principal assistance. 

And what of the forceps ? Bonnet says, " On devrait appliquer le forceps 
sil survenait quelqne accident pressant." Possibly such occasion may arise, 
but Caseaux makes use of the following remarkable language, under another 
head (General considerations on employment of forceps) : " Lastly, it has 
been shown how a brevity of the cord may become a cause of dystocia. 
When this happens the forceps is a hazardous resource, that ought to be 
' avoided ; but the real source of the delay is generally unknown, and even if 
it were not I know of nothing better to be done." 

Such conflicting statements certainly justify the expectant practice, and 
reduce our agency to depressing the fundus of the womb when circumstances 
require it, and of using the scissors when the natural efforts bring the coils 
of the cord in reach, provided we cannot slip them over the head or shoulders 
without violence. 

Subsidence of the Womb eight weeks before labour. — On the 7th of May I 

was called to Mrs. , who complained of severe pains in the loins after 

some unusually active exercise the day before. During the night the womb 



124 



McSherry, Obstetrical Memoranda. 



[July 



had subsided, as it usually does shortly before labour. She had previously 
engaged my services for the early part of the month of June. I advised rest, 
and mild counter-irritation, telling her the labour was nearer than she antici- 
pated. Her husband, a very active man of business, was about going to the 
West for two or three weeks, but as he did not wish to be absent during her 
confinement, I counselled him to remain at home. The lady soon became 
tired of restraint, finding herself generally comfortable, and she was not con- 
fined until the 5th of July, when her second child was born. There was 
some tendency to uterine hemorrhage in excess, which was soon brought 
under control — otherwise things were as usual. I do not know if this early 
subsidence is often observed by gentlemen in large obstetrical practice, but 
authorities generally assign it to the last two weeks, if not to the last few 
days of utero-gestation. Duges, indeed, says that " the subsiding is generally 
observed only in the last months of pregnancy other authors pretty uni- 
formly allow weeks or days only. 

Hydrocephalus protracting Labour. — Mrs. M. 7 set. about 40, was confined 
with her first child on the 12th of May, 1855. The waters broke during 
the first hour of labour pains, after which the pains kept up well for twenty- 
three hours more before the child was born. I attributed the delay to the 
age and embonpoint of the mother. The child's head was not excessively 
large, though I observed a peculiar sponginess or elasticity of the cranial 
bones, before the birth. This was the only indication of a then existing dis- 
ease, which some six or seven weeks subsequently displayed itself very mani- 
festly — the head had become enormously large, with distinct sense of fluctua- 
tion under the anterior fontanelle, &c. The general health did not seem 
impaired. I commenced a course of treatment which did not arrest the con- 
tinued progress of the disease, whereupon the parents consulted, in turn, 
several other physicians with no better results, for it still lives in the same 
condition. 

Leather Pessaries. — In January, 1855, I was consulted by a poor woman, 
a widow, the mother of several children, for a complete prolapsus of the 
womb. That organ was enlarged to the dimensions of a good sized orange, 
and protruded considerably from the vulva. There happened to be in my 
office at the time some leather rings or disks, intended for a very different 
purpose (washers), but it occured to me they would give temporary support 
until some more permanent instrument should be applied. I accordingly 
restored the womb, and introduced one of the rings after oiling it, but as it 
appeared too flexible, I introduced a second. Both together made a very firm 
support. The woman, who earned her daily bread by hard labour, had been 
long suffering, but had not sought relief until that time, when she had be- 
come quite disabled. I directed her to report progress to me from time to 
time, and found her soon again at the wash-tub, suffering little or no incon- 
venience from her disease. There was no reason to change an instrument 
which answered so well, so she wears it still, and gets on very comfortably. 

The entire diameter of the ring is two inches eight lines ; of the circular 
space within, one inch eight lines. 

The above cases, perhaps, present nothing new to many of your readers, 
but they appear to be sufficiently different from the routine of every-day 
practice to be worthy of being recorded. 



Baltimore, March 15, 1856. 



1856.] 



Nott, Wire Splints. 



125 



Art. VIL— On Wire Splints. By J. C. Nott, M. D., of Mobile, Ala. 



I have recently been using in fractures of the extremities wire splints, 
which I do not recollect to have seen recommended elsewhere, and which 
possess manifest advantages over those of any other material heretofore used. 

The objections to wood, pasteboard, gutta percha, and other solid materials, 
are that they keep the inflamed parts too warm, and do not admit the appli- 
cation of cold water. 

The " wove wire" is the lightest material out of which a firm splint can be 
made, and being malleable, may be moulded with the fingers to the shape of 
the limb. 

Being porous, no obstruction is offered to the entrance of cold lotions, and 
the parts may be subjected, if necessary, to a stream of water. 

The material out of which these splints are made is easily procured and 
easily cut into proper shapes. The hardware stores all keep what is called 
" wove wire" of various qualities, coarse and fine, and with a pair of strong 
shears it is readily cut into any form we may desire. The edges should be 
turned over to prevent the wires from sticking into the flesh, and to give more 
strength to the splint. It is well also to give them a coat of asphaltum or 
other varnish, to keep them from rusting. The material does not cost more 
than from fifty cents to one dollar a yard. 

Figures 1 and 2 will give an idea of these splints. 

Fig.l. 







-,i 






II 




Suppose, for example, we have a common fracture of the bones of the leg. 
Two splints of the shape of Fig. 2 are selected, and being well padded with 
lint or old soft rags, they are applied on each side of the leg, and nicely 
moulded to its shape. A bandage is then rolled from the toes up to the 
knee over it, or what is more simple, pieces of bandage are tied around at 
short spaces from toes to knee. "We at once have a solid fixture, having all 
the advantages and none of the inconveniences of the starch bandage, and 
the patient may move the limb about as he pleases, or get up on crutches. 
No. LXIIL— July 1856. 9 



126 



"Wright, Liquidambar Styraciflua. 



[July 



Art. VIII. — On Liquidambar Styraciflua. By Charles W. Wright, 
M. D., Professor of Chemistry in the Kentucky School of Medicine. 

Liquidambar Styraciflua, commonly called sweet-gum, is indigenous to 
nearly every part of the United States, and constitutes one of our largest forest 
trees. When an incision is made through the bark of this tree, a resinous juice 
exudes, which possesses an agreeable balsamic odour. When this substance 
first exudes, it is of the consistence of turpentine, and possesses a stronger 
smell in that condition than it does after it has become resinified. Contrary 
to the statements made by Wood and Bache, in their Dispensatory, this tree 
furnishes a considerable quantity of resin in the Middle States, particularly 
in the States of Ohio, Indiana, and Kentucky, bordering on the Ohio River. 
It is annually collected in those States, and sold under the name of gum-wax. 
It is a much more agreeable masticatory than the spruce-gum, and is chewed 
in the West by nearly all classes. By proper incisions, one tree will yield 
annually about three pounds of the resin. 

The chemical composition of the specimens collected in this latitude corre« 
spond with that given by M. Bonastre, of specimens gathered elsewhere, viz : 
benzoic acid, a volatile oil, a semiconcrete substance separated by distillation 
and ether, an oleo-resin, a principle insoluble in water and cold alcohol, termed 
styracine. The bark of the tree contains tannic and gallic acids, to which its 
astringency is due. 

What I wish more particularly to call attention to is the employment of a 
syrup of the bark of this tree, in diarrhoea and dysentery, and more espe- 
cially the diarrhoea which is so prevalent among children during the summer 
months in the Middle States, and which frequently terminate in cholera 
infantum. 

The best formula for the preparation of this syrup is that given in the 
United States Pharmacopoeia, for the preparation of the syrup of wild-cherry 
bark, of which the following is a copy, the sweet-gum bark being substituted 
for the wild-cherry bark. 

" Take of sweet-gum bark, in coarse powder, Jive ounces ; sugar (refined) 
two pounds; water a sufficient quantity. Moisten the bark thoroughly with 
water, let it stand for twenty-four hours in a close vessel, then transfer it to a 
percolator, and pour water upon it gradually until a pint of filtered liquor is 
obtained. To this add the sugar in a bottle, and agitate occasionally until it 
is dissolved." 

The dose of this syrup for an adult is about one fluidounce, to be given at 
every operation, as long as the operations continue to recur too frequently. 

One advantage which this medicine possesses over most astringent prepa- 
rations is that of having an exceedingly pleasant taste, and of being retained 
by an irritable stomach when almost every other substance is rejected. Child- 



1856.] 



Porter, Inversion of the Uterus. 



127 



ren never object to it on the score of bad taste. The resinous and volatile 
bodies which it contains, no doubt enhances its value. My brother, Dr. J. 
F. Wright, of Columbus, Indiana, has employed this preparation for the past 
three years in a great number of cases, with the most satisfactory results. He 
prefers it to any other article where there is an indication for astringent medi- 
cation in the class of diseases before referred to. In the bowel complaints of 
children it has a decided advantage over all preparations containing opium, 
and I am always pleased with the happy results which follow its employment 
in that class of patients. 



Art. IX. — Inversion of the Uterus 7 replaced on the Third Day. By Isaac 
G-. Porter, M. D., of New London, Conn. 

Cases of this accident are, it is well known, extremely rare in hospital 
practice; less so, doubtless, for obvious reasons, than in the experience of 
practitioners at large; a late article in this journal showing, from the statis- 
tics of certain English lying-in establishments, that they occur scarcely less 
frequently than once in 85,000 labours. Always alarming, and frequently 
fatal, a certain amount of interest always attaches to them, but the point 
especially inviting attention in the following case, is the length of time that 
elapsed after the inversion before its replacement. It would not be difficult 
to surpass it, in this respect, by a reference to recorded experience of remark- 
able cases; but if this notice shall encourage perseverance in similar instances, 
its object will be attained. 

A lady, thirty years of age, of delicate organization, though of uniformly 
good health, was confined in the country, at 4 o'clock A. M., Tuesday, 
March 18th, under the care of a neighbouring practitioner. The labour was 
not severe, lasting but little over four hours, but the delivery of the placenta 
was delayed one or two hours, doubtless owing to atony of the uterus. It 
came away somewhat disrupted, although the physician disclaimed having 
used any undue interference. Previous, and subsequent to its delivery, there 
was much flooding, attended with great faintness, prostration, nausea, &c. 
Some hours after, she partly arose in bed, to urinate, when the uterus made 
a complete descent, through the external parts, forming a tumour the size of 
" two fists." Increased prostration, and much alarm and distress followed 
the shock which the system sustained from the abnormal displacement and 
the downward pressure of the contents of the abdomen, as well as from an 
entire inability to pass water. This function was not performed, after the 
accident, until the re-inversion of the uterus, except as the mass was crowded 
upwards by manual assistance, thus relieving the pressure on the urethra ; 
and on my arrival, I found the protruded body partially returned, within the 
vagina, where it was supported by a pessary, or tampon, resting externally 
on the bed. The physician and patient both informed me, that great relief 
followed this partial reposition, she being enabled thereby to pass water, yet 



128 



Porter, Inversion of the Uterus. 



[July 



with difficulty, while, by the same means, the traction of the uterus, on its 
ligaments, was considerably lessened. 

The patient resided about twenty miles distant, and I did not see her until 
Thursday eve, at 8 o'clock, almost three days after the accident. The fore- 
going account I received from the physician in attendance. At this time, 
moderate reaction had come on — countenance anxious and deadly pale, pulse 
120 and irritable. There was much distress and tenderness in the abdomen, 
flooding not severe, since the complete inversion, and immediate danger to 
life did not appear imminent. An examination confirmed the suspicion of 
inversion. The vagina was filled with a firm, yet compressible, globular, and 
sensitive mass, answering the usual description of books — no os tincae was 
discovered, but there was a marked fold of the vagina encircling the tumour, 
which is mentioned in this place as being confirmatory of the opinion that 
this constitutes a valuable diagnostic between inversion of the uterus and 
polypus. Gentle, but gradually increasing force with the back of the flexed 
fingers caused the mass to diminish in size, and slowly to ascend in the 
direction of the superior strait. As it grew less in dimensions it was more 
easily grasped, and ultimately, the uterus, with the hand encircling and com- 
pressing it, was used as a stem, with which upward pressure was exerted. 
Under this compound action of compression and elevation, the restoration be- 
came much more rapid. Owing to extensibility of the soft parts, consider- 
able counter-pressure on the abdomen became necessary. The sensation 
communicated to the hand was very different, when the parts were returned 
as far as the os tincae and the uterus, in which latter, the regular process of 
involution had evidently commenced. There was less resiliency in the 
uterus at the last stage of the operation than is common, immediately after 
delivery — but rather a spontaneous yielding to slight force, with one or two 
fingers; these were retained in the cavity for some minutes after the comple- 
tion of the operation, which occupied about twenty-five minutes. Immediate 
relief followed, the uterus resumed its place in the hypogastrium, and the 
abdomen became much less tender on pressure. Under the influence of a 
stimulant, and an opiate, the patient enjoyed her first sleep since her confine- 
ment. The horizontal position for a week was strictly observed, and there 
being incontinence of urine for a few days, the catheter was uncalled for. 
Some febrile excitement existed in the form of thirst, frequent pulse, and 
much pain in the back. The lochia were sparing, and the secretion of milk 
never occurred. The countenance was blanched and leucophlegmatic, and 
there was anaemic headache. 

On the 13th day, while attempting to sit in a chair for the first time, a 
severe pain in her right hip and leg seized her, which was the commencement 
of a mild attack of phlegmasia dolens. For two days the pain was extreme, 
as was the tenderness in the tract of the femoral vessels. The case, however, 
speedily yielded, verifying the principle, that the later the attack after partu- 
rition, the more amenable to remedies. Laxatives, alternated with opium, 
and fomentation, repeated every four hours, and followed with gentle friction, 
with warm tinct. of aconite, and tinct. of opium, aa 1 part, and ol. oliv. 2 
parts, were speedily successful in relieving the pain. Contrary to my expec- 
tation, a flannel bandage, reaching from the toes to the hips, was, even at an 
early stage, conducive to comfort, and she continued to wear it, for support, 
until she passed from my observation. 



1856.] 



129 



REVIEWS. 



Art. X. — Physical Exploration and Diagnosis of Diseases affecting the 
Respiratory Organs. By Austin Flint, M. J)., Professor of the Theory 
and Practice of Medicine in the University of Louisville, &c. 

The time was when a medical man could, within the covers of a single 
volume, find almost all that was to be found of medical science ; and he was, 
indeed, a happy man and a painstaking student who was able and willing to 
consult more than the one author, whose theories he had learned and whose 
disciple he had become. Within the memory, indeed, of not a few of our 
profession, a single treatise upon the theory and practice of physic was 
all that most practitioners ever cared to read. Experience was the one de- 
pendence of our profession, and years were supposed to bring wisdom. The 
man of largest experience was he who had seen the most cases, and he often- 
times resigned practice, only confirmed in the notions which he had erro- 
neously acquired while riding with his instructor. 

To-day we have the profession cut up into specialties. For every region 
we have treatises, and for every disease a monograph. There are many who 
doubt the expediency of so dividing our labours and our studies ; who think 
a man a better physician for being a good surgeon, and a far better surgeon 
for being a good physician. This is, to a very great extent, true. But the 
truth does not so appear from anything inherent in the practice of physic or 
surgery, but because men who practice one branch are so apt to consider 
every other as secondary to their own. To act promptly and efficiently, a 
physician should neglect the reading of no part of medical science. He is 
not fit for a physician unless he understands physiology, nor for a surgeon 
unless he has a practical acquaintance with mechanical laws. 

The same train of thought is applicable to the diagnosis of diseases of the 
chest. Men are still in successful practice who ridicule the idea of physical 
exploration j and it is to be feared, that many of our younger brethren pay 
such perfect deference to physical signs, that they allow rational signs of the 
utmost importance to escape them entirely. 

Such men are not followers of the school to which the author of the treatise 
on Physical exploration and diagnosis of diseases affecting the respiratory 
organs, belongs. He has given us over six hundred pages upon this single sub- 
ject. And they are six hundred pages of very readable and most instructive 
matter, in a clear and comprehensive style. We wished, on seeing the book, 
that it had been more condensed j but, after reading it through, we are un- 
able to point out anything which should have been omitted. The book is 
founded upon facts, which have come under the author's own patient observa- 
tion, and which have been judged by careful comparison with each other, and 
with the experience of other labourers in the same field with himself. 

But, it may be asked, why write this book at all ? Is not the literature of 
the chest already ample ? Is not the field already crowded ? The answer is 
very easily given; not so long as any careful and intelligent observer has any 
observations and opinions to communicate. And no one, in our opinion, can 



130 



Reviews. 



[July 



read Dr. Flint's treatise, without feeling satisfied that he has contributed to 
our medical literature a work of original observation of the highest merit. 

We always read a preface, because we can learn from it whether a book is 
worth our study. We do not think it any vanity in a writer who finds that 
he disagrees with others, and tells us that he does not hesitate to follow a rule 
"which, in matters purely of observation, should not lead to the imputation 
either of egotism or presumption, viz., not to be more ready to distrust one's 
own accuracy than that of others." Dr. Flint tells us, in his preface, that 
"questions have so frequently arisen which are to be settled only by an 
appeal to the results of observation, that I have sometimes been tempted to 
lay aside the pen, and have resumed it only under the conviction that such 
questions must for a long period continue to arise j and that to wait for the 
means of meeting promptly every inquiry, is equivalent to an indefinite post- 
ponement." 

The writer of this review is thankful that the author continued his work. 
With all the merit which belongs to the treatise of Professor Walshe, that 
book is very hard reading. The work of Skoda, which has come to us at a 
later day, we read without carrying off anything which gave us pleasure. The 
latter reminded us too forcibly of the painful studies of our collegiate course, 
which we were too glad to finish. 

The work of Dr. Flint is eminently a readable one. 

The introduction is devoted to the consideration of preliminary points per- 
taining to the anatomy and physiology of the respiratory apparatus. The 
modifications caused by sex and age, the differences of motion and of sound 
in different portions of the same side, and the comparatively similar, but not 
like parts of the two sides are fully examined. To the neglect of precaution 
in testing these differences, the examiner of moderate practice has occasionally 
condemned a patient to a fatal disease, whose recovery in other hands has 
caused him to lose confidence in the usefulness of physical exploration ) or, 
more happily, has taught him to review his studies and correct his errors. To 
the one, experience is of no value ; to the other, its value is inestimable. 
Some such experience probably induced Dr. Flint occasionally to amplify, 
a somewhat after the usual mode of oral teaching," and occasionally to repeat 
where otherwise he would have consulted brevity. 

The words bronchi, bronchia, bronchice, are frequently used throughout the 
book. It seems to us that physicians are not sufficiently careful to adhere to 
the true words. The Latin bronchus and Greek pgoyxo$ have neither neuter 
nor feminine plurals. To be sure, gentlemen make the distinction of bron- 
chus and bronchia between the primary and secondary divisions of the trachea, 
and we believe some medical dictionaries have done the same, but the dis- 
tinction is arbitrary. If it were the universal custom to make such distinction, 
it might perhaps be allowable, but the same writer will frequently use the 
different words to express the same idea, and thus cause confusion. Primary, 
secondary, ultimate bronchi, would be a better and more accurate nomencla- 
ture. We may be accused of being hypercritical in relation to this matter, 
and certainly if we can find no greater fault with the book than this, it can 
hardly be deemed a very venal one. 

Except in the original paper of Dr. Dalton, we have not before seen any 
notice of the experiments upon the respiratory movements of the glottis. 
These experiments, showing that " during normal respiration there is a con- 
stant and regular movement of the vocal chords, by which the size of the 
glottis is alternately enlarged and diminished, synchronous with the inspira- 
tory and expiratory movements of the chest," will be of much service to us 



1556.] 



Flint, Diseases affecting the Respiratory Organs. 



131 



in the treatment of those spasmodic symptoms which we see so frequently in 
true and false croup. We may learn the propriety of putting young patients 
under the influence of narcotics or anaesthetics, sufficiently to enable us to 
destroy the irregular innervation by local or constitutional remedies. 

The first part of Dr. Flint's book, to the three hundred and forty-sixth 
page, is taken up with the Physical Exploration of the Chest. This is the 
scientific part. It teaches how to examine the causes of the sounds we hear, 
the reasons why they differ, the methods of comparing them with each other, 
and indirectly the dangers of trusting too confidently to what has been writ- 
ten, without careful comparison of the examinations of others with our own 
observations. 

Percussion and auscultation are the means mostly made use of, to discover 
what are called the physical signs. There are other means of less value in 
most cases of respiratory disease, but occasionally the practice of inspection, 
palpation, mensuration, and even succussion, will give us aid in the greatest 
degree. It is not necessary that we should all understand the science of 
acoustics ; and should we at the outset consider such knowledge essential, we 
should find but few of our profession capable of conducting the simplest ex- 
amination. There are certain principles of acoustics, however, which every 
man of moderate abilities may learn, which no physician of our day should 
be ignorant of, though he may not even know the meaning of the word. 
To the same extent a mechanic may be able to build his wall, who knows 
nothing of the gravity which keeps his plumb-line perpendicular. 

" It is a common impression with those ignorant of the subject, that the signs 
generally represent uniform and definite morbid conditions ; in other words, 
that each sign possesses its own special significance ; and therefore, for the 
practice of physical exploration, that it is simply necessary to be able to recog- 
nize and appreciate certain abnormal sounds. According to this view, physical 
exploration is merely a mechanical art. This is implied when symptoms, as 
distinguished from signs, are called rational. The inference is, that to deter- 
mine the value of signs, processes of reasoning are not required : that they 
express in themselves their full import, and that the ability to discriminate 
different diseases thereby depends mainly on manual tact and the cultivation of 
the senses. The student should, as soon as possible, dispossess the mind of 
this error. Few signs, individually, are pathognomonic. Their diagnostic sig- 
nification depends on their combination with other signs, and on their connec- 
tion with symptoms. Hence, something more than delicacy of hearing and 
skilful manipulation is requisite. Thought and the exercise of judgment are 
needed, not less than in determining the nature and seat of diseases by their 
vital phenomena. In short, physical exploration develops a series of facts 
which are to be made the subjects of ratiocination in their applications to 
diagnosis, as much as facts obtained by other methods. 

"To be convinced of the great benefit which practical medicine has derived 
from the introduction of physical methods of exploration, it is only necessary 
to contrast the facility of discriminating the most common pulmonary affections 
at the present time, with the difficulty which confessedly existed prior to the 
employment of these methods. If the reader will turn to the works of Cullen, 
or the more recent writings of Good, he will find that these authors acknow- 
ledge the inability of the practitioner often to distinguish, by means of symp- 
toms, pneumonitis, pleuritis, and bronchitis from each other, so that for prac- 
tical purposes it was deemed sufficient to consider these three affections as one 
disease. At the present time, with the aid of signs, it is very rarely the case 
that the discrimination cannot be made easily. And that this improvement is 
mainly due to physical exploration, is shown by the fact, that to distinguish 
these affections by means of symptoms alone, is still nearly as difficult as here- 
tofore. But to realize the importance of the subject it is not necessary to insti- 
tute a comparison of the present with the past. It is sufficient to refer to the 



132 



Reviews. 



[July 



mistakes in diagnosis daily made by practitioners who rely exclusively on 
symptoms, which might be easily avoided by resorting to physical signs. It 
may not be amiss to cite some illustrations from instances that have fallen under 
my own observation. Examples of confounding the three affections just named 
are sufficiently common. Of these affections, pneumonitis and pleuritis are not 
unfrequently latent, so far as distinctive vital phenomena are concerned, and 
consequently are overlooked. Chronic pleurisy is habitually mistaken for 
other affections by those who do not employ physical exploration. Of a con- 
siderable number of cases, the histories of which I have collected, in a large 
proportion the nature and seat of the disease had not been ascertained. 1 Yet 
nothing is more simple than to determine the existence of this affection by an 
exploration of the chest. Acute pleuritis and pneumonitis are sometimes com- 
pletely masked by the symptoms of other associated affections, and thus escape 
detection. This is observed in fevers, and when head symptoms become de- 
veloped, especially in children. Under these circumstances, the practitioner 
who avails himself of physical signs is alone able to arrive at a positive conclu- 
sion as to their existence. Emphysema is an affection which cannot be recog- 
nized by symptoms alone, and hence, they who neglect signs have no practical 
knowledge of it. Acute tuberculosis I have known repeatedly to be called 
typhoid fever; on the other hand, I could adduce numerous examples of differ- 
ent affections erroneously considered to be phthisis, and a still greater number 
of instances in which patients with this affection were incorrectly supposed to 
be affected with some other disease than tuberculosis. Were we to dwell upon 
these, and other mistakes which might be added, it would be easy to show that 
they are unfortunate, not merely in a scientific point of view, but with reference 
to practical consequences involving the welfare, and it may be the lives of 
patients." Pp. 66-G8. 

Physical signs and symptoms have each their value. Taken together, they 
tell us all that can be of avail in treatment. Separate them, and we are in 
constant danger of making mistakes. Who does not recall cases of haemo- 
ptysis, which would once have divided a man from his family, perplexed him 
in his business, condemned him to expensive travel, and a regimen which, if 
it did not kill him, would have rendered his very existence a burthen ? The 
use of physical signs enables us to tell him that he has no disease incompatible 
with a long and useful life, and teaches us to look elsewhere for a cause that 
may be removed. But these signs alone are of little value. They must be 
detected repeatedly in the same case, but they must be compared with the 
rational. 

"By thus directing attention," says Dr. Flint, "to some of the points .of 
contrast between symptoms and signs, it is not to be concluded that these two 
classes of phenomena hold conflicting relations in the practice of medicine. 
Neither is to be employed in diagnosis to the exclusion of the other. They are 
not to be disconnected save for abstract consideration. They are alwaj^s to be 
brought to bear conjointly in clinical investigations ; combined, they lead to 
conclusions which neither may be competent to establish alone. They mu- 
tually serve to correct or confirm deductions drawn from either separately. It 
is never to be lost sight of in the study or practice of physical exploration, that 
to devote too exclusive attention to signs, is as much a fault as to ignore their 
value, and rely entirely on symptoms." P. 69. 

We have often wondered that so little attention has been paid to this com- 
parison even by physicians in city practice. It is their fault, not their mis- 
fortune, which prevents their acquiring a reasonable knowledge of physical 
exploration. Some men learn very easily to detect differences in sounds, and 
some require untiring labour; but with a single patient a practitioner can 
learn, if he is willing to use the means nature has given him. One of the 



1 Vide Clinical Report on Chronic Pleurisy, by the author. 



1856.] Flint, Diseases affecting the Respiratory Organs. 133 



greatest merits of Dr. Flint's treatise is, that it teaches us as much about 
healthy as diseased signs. Writers have generally been satisfied to say, that 
in one part of the chest we shall find vesicular respiration and resonance, in 
another blowing respiration and resonance; again dulness, and here tym- 
pany. But a large part of this book tells us, what students do not always 
know how to find and where to find certain sounds in health as well as in 
disease. One who never examines a chest, unless he suspects disease there, 
throws away the most essential means of discovering disease. In the hos- 
pital, almost every student listens for bronchial respiration and friction 
sound in pneumonic and pleuritic patients; but a few take every opportunity 
to listen at those chests, where they know that there is no other sound than 
that of healthy respiration. It is needless to say which become the most 
correct auscultators. He who studiously reads Dr. Flint's book, and examines 
the healthy chest will, at all events, learn that most important part of our 
professional knowledge, when not to treat a patient. 

Before entering upon the study of abnormal sounds, it is desirable that 
one should be familiar with percussion in health. After guarding against the 
effect of irregular posture, and making allowance for the sounds produced by 
bodies against which the subject leans or reclines, the examiner is to bear in 
mind the fact, that the sounds elicited in the particular case are to be com- 
pared immediately with each other, secondarily with the sounds obtained in 
other cases. His own position must be such that, in passing from one point 
to another, upon the two sides, his relative position to the patient should be 
the same. This is of more importance than we are at first inclined to think. 
But no one can fail to be convinced of this who will invite a friend to percuss 
for him, while he is content to be an auditor only. Indeed, we are a little 
surprised that this course is not more frequently pursued • and we should have 
considered it another excellence in Dr. Flint had he laid stress upon it. We 
never should have been able, in any great degree, to appreciate Skoda's 
remarks upon the tympanitic sound of dull chests, if we had not listened to 
the exercise of a friend upon one of our own patients. 

There were twenty subjects selected, apparently free from disease, whose 
chests were symmetrical in conformation. In only eight was the percussion 
sound, over the infra-clavicular regions, equal on the two sides in all respects. 
In ten there was greater resonance on one side. In all these the resonance 
was greatest on the left. In one of these it was greatest over a certain por- 
tion of the right side. In eleven, the pitch of resonance was higher on the 
right side. In four instances, the vesicular quality of the resonance was 
greater on the left side ; never on the right. After showing other disparities 
in these apparently healthy cases, Dr. Flint says : — 

"Theoretically, in view of the greater capacity of the right chest, it would 
seem perhaps more reasonable that the difference between the two sides should 
be the reverse of that which is found to exist. The larger development of the 
right pectoral muscle, in consequence of the greater use of the right upper 
extremity, may account for the fact in some instances, but the disparity exists 
in cases in which there is no apparent difference in the muscular covering, in 
this situation. Possibly the different physical conditions at the base of the 
thorax may afford an explanation. On the right side the lungs repose, with 
the diaphragm intervening, on the liver, which occupies the whole of the base 
on that side. The presence of this solid viscus may slightly deaden the sound. 
On the left side below the lung is situated the stomach, frequently more or less 
distended with gas, and the effects of this, it may be supposed, is to increase 
the sonorousness on that side, even at the summit, independent of the trans- 
mission of the tympanitic gastric sound which is sometimes observed." P. 82. 



134 Reviews. [July 

The explanations are deserving of consideration. The author might have 
asserted his supposition without much danger of its being controverted. 

Over the scapular regions, in the same twenty patients, there was less dis- 
parity. In thirteen no difference was detected. In the remaining seven there 
was difference in pitch, intensity, &c. The scapular regions are less attractive 
to percussors, on account of the difficulty which many have of producing 
sounds, where the muscles are so thick. The ground has been taken that 
this region is of little value in physical exploration by percussion; but Dr. 
Flint truly says that, u like the infra-clavicular, it is an important region with 
reference to the physical signs of phthisis." With an assistant to percuss, it 
is remarkable how much light may be obtained even over this region of bone 
and flesh. Late in disease, there may be no necessity for noticing the sounds 
here; but it may be that the first confirmatory sign of chronic disease will be 
found here. The same remarks will apply to the mammary region in the 
female. 

When the student has gained expertness in the study of healthy chests, he 
is fitted for the study of percussion in disease ; and by this time he has ac- 
quired so large a part of the desired knowledge, that percussion in disease 
will have but few difficulties to contend with. 

Percussion in disease gives us not merely a new set of sounds, but we 
recognize those previously heard, but often in new situations. The abnormal 
sounds are divided into I. Exaggerated vesicular resonance; II. Diminished 
vesicular resonance ; III. Absence of Resonance ; IV. Tympanitic resonance. 
Under these four heads, with as much clearness as can be expected, are in- 
cluded all the sounds we have been accustomed to call by the terms clear, 
dull, flat, amphoric, tubular, &c. 

The importance of understanding the indications of percussion sounds, is 
illustrated, on page 105, by the supposed instances of pneumonitis and 
tubercle. 

Tympanitic resonance under peculiar circumstances is the percussion sound, 
to which our attention has been more than usually attracted of late. It must 
be remembered that there is a tympanitic dulness as well as a tympanitic 
clearness; just as there is a tympanitic sound from tapping on a tenor drum, 
or by pounding on an eighteen inch wall. The examination of a pleuritic or 
pneumonitic patient often ends with detecting a level for the fluid, or the 
limit of probable hepatization. Many are still not aware, that the master's 
hand can bring sounds from many a dull spot, and these will find in Dr. 
Flint's book a description of tympanitic dulness. 

Tympanitic resonance may mislead the careless. Without particular atten- 
tion to the facts, it is said that mistakes may be and have been made ; that 
the diseased side has been taken for the healthy one and vice versa, because a 
morbid resonance was used as a standard of health. 

"The rationale of the foregoing interesting and important facts is a matter at 
present sub judice, and inasmuch as I have no fruits of personal experiments 
or researches to offer, I shall not engage in a lengthened discussion of the sub- 
ject. To account for an exaggerated tympanitic resonance under circum- 
stances in which it is clinically exceptional, and apparently opposed to the 
laws of physics, viz., when the lung is compressed by the presence of liquid, 
or rendered more dense than natural by solidification, the doctrine has been 
advanced by Skoda that " if the lung contains less than its normal quantity of 
air, it yields a sound which approaches to the tympanitic, or is distinctly tym- 
panitic." 1 He bases this doctrine on experiments made upon the pulmonary 



1 Markham's translation, Am. edition, page 47. 



1856.] 



Flint, Diseases affecting the Respiratory Organs. 



135 



organs in the dead subject, and also removed from the body, taken in connec- 
tion with the facts pertaining to disease which have been presented. Clinically 
this doctrine cannot be considered to hold good in the light of a general law, 
for abnormal sonorousness in cases in which the lungs are to a greater or less 
extent deprived of their normal quantity of air, in other words rendered more 
dense by disease, is by no means an invariable sign, but, on the contrary, 
occurs only as an exception to the general rule. The sign, therefore, cannot 
be due simply to the mere deprivation of air, or any constant condition, but to 
some contingent circumstances. The question, then, is, what are these con- 
tingent circumstances? In cases of effusion within the pleura, the natural 
effect is to condense the lung by compression of the liquid ; but it is not cer- 
tain that in all instances the proportion of air to the solid tissues above the 
level of the fluid is diminished. By the force of the inspiratory movements 
causing greater dilatation of the cells, the ratio of air may perhaps even exceed 
the limits of health. It is not improbable that the origin of the emphysema 
and dilatation of the bronchiae which sometimes succeed pleurisy may have a 
date anterior to the absorption of the effused liquid. These are points which 
claim investigation." P. 117. 

We believe it to be much more easy to acquire facility in reading auscul- 
• tatory than percussion sounds. The one requires a correct ear only; the other, 
to be of value in doubtful cases, requires a musical ear and a nicety of touch 
which a large number of our profession never obtain. This seems to be the 
opinion of Dr. Flint. The several methods of auscultating respiratory sounds 
are fully described by him. Like the generality of examiners he concludes, 
that neither mediate nor immediate auscultation should be cultivated or 
practised to the exclusion of the other. Our own opinion is, that the imme- 
diate application of the ear to the chest is to be preferred by practitioners 
generally. Those who make the treatment of respiratory diseases a spe- 
cialty, acquire by practice an ability to vary their course, and their instru- 
ments, which others never can. The ability to hold a stethoscope, so as not 
to make a noise with one or the other end of it, is an elegant accomplishment. 
Cammann's flexible stethoscope with double tubes, is recommended by Dr. 
Flint, in cases where a delicate examination is necessary. But we are in- 
clined to the opinion, that, unless constantly used, it will fail to be of any 
service except to specialists, and to those whose sense of hearing is impaired. 
The author states, that in using the instrument "it is to be borne in mind, 
that it conducts sounds produced exterior to the chest, in no less a degree 
than those emanating from within." It is by no means certain, that even 
muscular sounds, within the body of the examiner or of the patient, might be 
metamorphosed into respiratory sounds. 

The rules for auscultating are well laid down, and it is advised to accustom 
one's self to the use of either ear, if the hearing be equally acute in both, 
that change of position on the part of the explorer may not be necessary. 

As percussion sounds in health are described at length, so are the auscul- 
tatory sounds. The sections devoted to auscultation in health, we consider 
the most valuable portion of the book. So important is this part of our 
study, that we should take frequent occasions for examining those whom we 
believe to be in normal condition. a Incongruous as it may at first appear, 
it will be found to be true, that certain of the most valuable of the physical 
signs involved in diagnosis, may be studied in persons entirely free from 
disease." 

The examinations of forty-four healthy persons furnished the material for 
analysis. Like percussion sounds, auscultatory sounds are only valuable 
when properly compared. Any one by itself means nothing, or it may mean 
anything. Subjects must be compared with each other, and the two sides in 



136 



Reviews. 



[July 



each subject. Due allowance must be made for the size, age, sex, fulness of 
flesh, temperament, &c, and in disease, even the time of day must be noted; 
else we may find dulness and absence of respiration or coarse rales, where, at 
another hour, another physician would positively and truly assert, that there 
was abnormally increased resonance and tubular respiration. 

The two sides are different in formation. One lung has three lobes, the 
other two. One has the liver below it, the other the stomach. The heart 
occupies more of the left chest than of the right. These differences were not 
in the course of our early studies so forcibly placed before us as of late, and 
still less were the variations in sounds. We have not space enough to review, 
even slightly, all that is said of the different sounds heard in the healthy 
chest. The following extracts from the sections upon Vesicular Respira- 
tion, will sufficiently illustrate Dr. Flint's method of making his analysis, as 
well as the style of the book. 

" 1. Inspiratory Sound. — In sixteen of twenty-four cases, more or less differ- 
ence as respects intensity between the two sides was appreciable. In all but 
one of these sixteen instances the inspiratory sound was more intense on the 
left side. This result is in direct opposition to the statements of some authors ; l 
but the matter is purely one of observation, and as the comparisons were made 
with care, and with no expectation of arriving at such a result, I am bound to 
assume its correctness. I can only account for the opinion of observers that 
the inspiratory sound on the right side is frequently more intense than that of 
the left, by supposing that elevation of pitch has been mistaken for increased 
intensity. The disparity in intensity was in some instances very marked. An 
inspiratory murmur was occasionally tolerably developed on the left side, and 
scarcely audible on the right. A striking difference was also in some cases 
observed in the effect of forced respiration on the intensity of the inspiratory 
sound, the intensity on the left side being proportionately increased, without 
any augmentation on the right side. 

<c In the relative amount of vesicular quality a difference was appreciable in 
a large proportion of the cases. And in all the instances in which a disparity 
in this particular existed, the greater amount of vesicular quality was on the 
left side. This was true in fourteen of twenty-four examinations of different 
individuals. The disparity in some instances was slight, but in several strongly 
marked; in not one instance was the vesicular quality greater on the right side. 

" Compared as respects the pitch of the inspiratory sounds, a difference was 
apparent in a large majority of the observations. Excluding a few cases in 
which attention was not directed to this point, of nineteen examinations, the 
pitch was higher on the right side in twelve, and no disparity was appreciable 
in seven; in not a single instance was the pitch higher on the left side. The 
difference here as with respect to the preceding characters, was in some in- 
stances striking, and in other instances slight. This numerical result does not 
vary much from that obtained by an analysis of the series of previous examin- 
ations. The latter numbered fifteen, and of these fifteen examinations the 
inspiratory murmur was higher in pitch on the right side in eleven, and no dis- 
parity was observed in the remaining four. 

" So far as the data just presented, then, furnish ground for deductions, a 
disparity between the inspiratory sounds at the summit of the chest in front, 
'exists in a large proportion of individuals free from all symptoms of thoracic 
disease, this disparity pertaining to the intensity, vesicular quality, and pitch. 
Variations in these three characters obey certain rules, viz., the greater relative 
intensity is almost uniformly on the left side. The same rule holds good with 
respect to a greater relative amount of the vesicular quality. On the other 
hand the greater elevation of pitch is always on the right side. 2 

1 Gerhard, Barth, and Roger. 

2 The relative duration of the inspiratory sound on the two sides is another point 
of comparison, to which attention was not directed in making the examinations. 



1856.] Flint, Diseases affecting the Respiratory Organs. 



137 



"2. Expiratory Sound. — Facts relative to the intensity of the expiratory sound 
on the two sides are contained in the notes of nine examinations. Of these 
nine comparisons, in three instances an expiratory sound was appreciable on 
the right side, and none on the left side; in two the development on the right 
side was greater than on the left, and in three the intensity seemed equal on 
the two sides. 

"In several instances the expiratory sound on the right side was prolonged, 
sometimes being nearly or even quite as long as the inspiratory ; on the con- 
trary, the expiratory sound, when present on the left side, was always short, 
never exceeding one-third of the duration of the inspiratory. It is noted in 
several instances that the expiratory sounds on the right side seemed distant 
from the ear. 

" In several instances, on the right side, a brief interval separated the sounds 
of inspiration and expiration. In every instance, on the other hand, on the left 
side, the two sounds were continuous. 

" The pitch of the expiratory sound was higher than that of the inspiratory 
on the right side in eleven instances, and on the left side in a single instance. 
It was lower on the left side in six, and on both sides in four instances. 

" According to the foregoing results, an expiratory sound exists on the right 
side in a certain proportion of cases in which none is appreciable on the left 
side. It is frequently prolonged on the right side, appears distant, and is sepa- 
rated from the inspiratory sound by an interval, and is higher in pitch. 

" The facts presented in the foregoing comparative account of the summit 
of the chest in front, may be seen at a glance by reference to the subjoined 
table. 

" Comparison of Bight and Left Infra-clavicular Regions. Whole number of 
examinations twenty-four. 
Inspiratory Sound. 
Right. Left. 
Greater intensity in 1 case. Greater intensity in 15 cases. 

Vesicular quality more marked in no Vesicular quality more marked in 14 
case. cases. 

Higher pitch of sound in 12 of 19 Higher pitch of sound in no case, 
examinations. 

Expiratory Sound. 
Right. Left. 
Present on this side, and not on left Present on this side, and not on right 
side, in 3 cases. side, in no case. 

More intense on this side in 2 cases. More intense on this side in no case. 
Prolonged in several cases. Prolonged in none. 

An interval between the sounds of in- The two sounds continuous, 
spiration and expiration in several 
cases. 

Pitch higher than that of the inspi- Pitch higher in 1 instance, 
ratory sound in 11 instances. 

Pitch lower than that of inspiration Pitch lower in 10 instances, 
in 4 instances. 

"Reviewing the facts pertaining to both the inspiratory and the expiratory 
sound, it is perceived that the several elements which have been seen to com- 
pose the bronchial respiration are manifested at the summit of the chest, in 
front, on the right side. This is a practical conclusion arrived at by means of 
the foregoing analysis. Assuming this conclusion to be correct, its importance 
will be apparent hereafter, in connection with the diagnosis of tuberculosis of 
the lungs in the early stage. In that connection, without knowledge of the 
facts which have been presented, it can hardly be otherwise than that error 
of diagnosis will be committed, by mistaking for the physical signs of disease, 
the several characters of the bronchial respiration which may exist at the 
summit of the right chest, not proceeding from a morbid condition. I am free 
to state that my own experience would supply illustrations of error from this 
source." Pp. 153-155. 



138 



Reviews. 



[July 



In like manner are the sounds of the healthy chest followed through the 
different regions. 

Auscultation in disease is for the purpose of determining morbid sounds 
and their differences from healthy sounds; to ascertain the connection between 
these and their causes, and to explain the morbid physical conditions. Ex- 
planation of the mechanism of these sounds is not necessary. However much 
we may differ as to the manner of production of a particular morbid sound; in 
our treatment of the case, as based upon its particular cause, we should not 
differ. The explanation Dr. Flint has, therefore, wisely omitted from his 
book, as tending only to provoke useless discussion, which would lead to dif- 
fering conclusions. 

Auscultation in disease furnishes modified and adventitious respiratory 
sounds; exaggerated, diminished, and suppressed vocal resonance; modified 
cough ; abnormal transmission of the heart sounds. When we say that one 
hundred and twenty pages are usefully occupied with these subjects, every 
one will understand, that the limits of this paper will not permit even a brief 
recapitulation which would do justice to the author. 

We shall, therefore, give a sketch of Dr. Flint's remarks upon a few of the 
more common and best known of the diseases of the respiratory organs. 
From these the readers of the Journal will be enabled at once to decide whether 
the work of the author has been properly done. 

As far as the three hundred and fiftieth page there is very little mention of, 
no dissertation upon, any distinct affection of the chest. Thus far, it is a work 
complete in itself. If the latter part of the book had not been published, the 
profession would still have a work of great value, and one which must here- 
after be looked upon as a standard in auscultation. Had the first part been 
published a year in advance of the second, we think it would have met with 
a ready sale, would have found more readers, and created a demand for the 
second. 

This is aside from our work, however. We are informed, in the prelimi- 
nary remarks, that we are not to make our diagnosis at the bedside by signs 
alone. There are physiological laws and symptoms which must guide us in 
our studies. Symptoms and signs must be balanced and compared. In 
pointing out the diagnosis of particular diseases, Dr. Flint bears this rule 
constantly in mind. 

No disease comes under our observation in which an early diagnosis is more 
necessary than pulmonary tuberculosis. From a careful examination of one 
hundred cases of this disease, Dr. Flint has drawn his conclusions. The ex- 
aminations of healthy chests are carefully considered in this connection. It 
is to be remembered, that there is a difference in the percussion and ausculta- 
tory sounds in the two sides of healthy well-formed chests. Distinct dulness 
in the left infra-clavicular region is of great significance ; on the right side, 
that same dulness is to be considered, but, as a morbid sign, taken with great 
reserve. There is a difficulty in percussing the post-clavicular regions, which 
most auscultators never entirely overcome. A disparity in this region is, 
therefore, to be distrusted when it is slight. Dr. Flint has noticed it, how- 
ever, when it was not appreciable in the clavicular and infra-clavicular regions. 
Percussion over the scapula has been considered of secondary importance. 
He attributes great value to it, because, from percussion in health, it is found 
that a natural disparity in the two sides behind is much less frequent than in 
front. It is necessary to percuss at different hours in the day ; because, when 
a cavity has formed, percussion early in the day will detect dulness, where, 
after an abundant expectoration, there will be a change to clearness of reso- 



1856.] 



Flint, Diseases affecting the Respiratory Organs. 



139 



nance. The auscultator is warned against deep percussion in cases of hemo- 
ptysis, because profuse hemorrhage has followed it so closely as plainly to show 
that accident to be a direct consequence of the violence used. 

There is no auscultatory sound which we may not find in phthisis. An 
attention to auscultation in health is, therefore, demanded. The presence or 
absence of prolonged expiration, we know, is often considered a sufficient 
evidence of the presence or absence of tubercle. We are taught that either 
inspiration or expiration may be absent to the ear. Occasionally, except with 
Cammann's stethoscope, the inspiration is inaudible; sometimes that alone is 
to be heard. There are other abnormal modifications which must then enter 
into the calculation. As the expiratory sound is sometimes wanting, so in 
others it is the only sound to be heard. Considering the signs discovered in 
health, it must be borne in mind that the character of the broncho-vesicular 
sound should be strongly marked at the summit of the right side, for it to be 
considered, in itself, an evidence of disease. On the other hand, if situated 
at the summit of the left side, it is much more significant of disease. 

" Moist crackling or mucous rales may, however, be produced by the escape 
of softened tuberculous matter into the tubes without necessarily involving the 
coexistence of circumscribed bronchitis. The development of moist or bubbling 
sounds is generally regarded as a circumstance distinctive of the fact that soft- 
ening has taken place. Undue significance, as it seems to me, has been attached 
to this circumstance. It is impossible to determine from the characters of the 
sounds whether they proceed from the presence of softened tuberculous matter, 
or from mucous secretions, or (as must be the case frequently) from both com- 
bined. And inasmuch as circumscribed bronchitis may undoubtedly exist 
before softening of the tuberculous matter ensues, mucous rales are heard before 
the disease has advanced to this stage. Not indicating necessarily softening, 
moist rales limited to the summit of the chest are highly diagnostic of tubercu- 
losis, and in cases of doubt it is useful to auscultate repeatedly, and especially 
in the morning before expectoration has taken place, in order to discover them, 
if they exist." P. 474. 

The diagnosis must, to a considerable extent, be made out from the pre- 
vious history. It is based on positive evidence. But its differential diagnosis 
requires more than we are enabled to discover by auscultation alone. 

"A cough, not originating from a distinct attack of acute bronchitis, and not 
preceded by coryza, but frequently commencing so imperceptibly that the date 
of its first appearance cannot be definitely ascertained : in degree slight, mode- 
rate, or violent, but persisting for some time with little or no expectoration. 
Dryness of the cough, continuing for a greater or less period, according to my 
experience, obtains in a larger ratio of cases than is estimated by Walshe, viz., 
one-tenth. I should say that careful inquiry of patients will show it to be the 
rule. An expectoration at first small, transparent, and frothy ; becoming 
. gradually more abundant, solid, opaque, yellow, and non-aerated, subsequently 
consisting of sputa streaked with yellow lines, particoloured, and frequently 
presenting irregular ragged edges ; occasionally including small particles 
resembling boiled rice, and a grumous-looking substance contained in a thinner 
fluid, like the deposit in barley water. According to Walshe, from whom is bor- 
rowed the description of the appearance last named, such a deposit occurs only 
in cases of phthisis. At a more advanced period purulent matter, in greater or 
less abundance, running together and forming an ash-coloured mass, with a nau- 
seous and occasionally fetid odor. Small fibres, supposed to be exfoliated elastic 
tissue, discovered by microscopical examination : also detached fragments of 
other of the anatomical elements of the pulmonary structure, and possibly, in 
some instances, the tubercular corpuscle. Acute stitch-pains at the summit of 
the chest, sometimes in front, oftener beneath the scapula ; recurring from time 
to time ; at times severe, and lasting for several days ; in other instances slight 



140 



Reviews. 



and of brief duration ; experienced more frequently on one side than on the 
other, hut often occurring successively, or in alternation, on both sides. These 
pains generally denote repeated attacks of circumscribed pleuritis. Chills, or 
shiverings, sometimes observing an approach to periodicity, and liable to be 
attributed to an irregular or imperfectly developed intermittent. Haemoptysis, 1 
frequently the first symptom to create alarm in the mind of the patient; some- 
times preceding other symptoms, and all appreciable physical signs/' 2 P. 489. 

We are told, with much truth, we believe, that dyspepsia is not a frequent 
cause of phthisis, and the same is said to be true of chronic pleurisy and 
pneumonitis. 

Acute phthisis is treated of in a few pages. More might have been said 
upon this subject with benefit, for we have reason to think that physicians 
have been, sometimes, unjustly blamed for not diagnosticating this affection 
in some short cases, where it was easily detected by other physicians a very 
few weeks or days subsequently. 

The diagnosis of pneumonitis and pleurisy are sufficiently easy to be made. 
Yet how frequently do we have cases come under our care where the previous 
diagnoses have been inaccurate. How frequently is it the case, that we are 
doubtful whether the young patient has a pneumonitis or an encephalitis? 
How frequently do we say that this patient has lung fever, while we cannot 
help a feeling of mixed doubt and certainty, whether it may not turn out to 
be a functional derangement after all. When fresh from the school, we feel 
vastly more competent to diagnosticate disease than we are found to be ten 
years later. This is in part owing to the fact, that each new class of gradu- 
ates has a partially new and more perfect system of diagnosis. It is in part 
due, also, to our having been oftentimes deceived and having learned caution. 
In the work before us, we believe that the signs of these two diseases are well 
laid down. 

" If a person be seized with a chill, which is followed by high febrile move- 
ment, and lancinating pain in the chest, referred to the neighbourhood of the 
nipple ; accompanied by cough, with an adhesive, rusty expectoration, and a 
well-marked crepitant rale is found on auscultating the posterior surface of the 
chest on one side, it is at once evident that he is attacked with pneumonitis 
seated in an inferior lobe." P. 421. 

No one can doubt the truth of this description, particularly when it is added 
that " a viscid expectoration, containing a variable quantity of blood in inti- 
mate combination, is a symptom belonging exclusively to inflammation of the 
pulmonary parenchyma/' 

But we are told that the crepitant rale maybe obscure; "the characteristic 
expectoration is by no means uniformly present in cases of pneumonitis, and, 
if not altogether absent, it is not always among the earlier symptoms of the 
disease ;" there may not be an excess of pain which can be fixed in any one 
part of the chest. These cases are not common, but they do sometimes occur; 
and it so happens that the writer of this article, by that strange coincidence 
which every practitioner will notice as having happened with some particular 
diseases, has seen this want of signs in a large number of his cases of pneu- 

1 The subject of haemoptysis in its relation to tuberculosis, has been elaborately 
investigated by Dr. Walshe; vide British and Foreign Medico-Chir. Review, January, 
1849. 

2 In 91 of the 100 cases which I have analyzed, as respects physical signs, the 
histories contain information concerning haemoptysis. It had occurred in 53 cases 
prior to the time of my examinations. Of 22 cases of small tubercular deposits, it had 
occurred in 13. Of 11 cases in which the existence of cavities was ascertained, it had 
occurred in 6. Of 58 cases of abundant deposit, it had occurred in 34. 



1856.] 



Huss, Typhus and Typhoid Fever. 



141 



monitis within the few years past. It is almost unnecessary to say, that there 
is something peculiar which prevents a practitioner from diagnosticating any- 
thing but pneumonitis in such cases. He of course gives a guarded diagnosis 
to the family. At length perfect dulness, unchanged by change of position, 
and bronchial respiration and voice, mixed with crepitus in some near spot, 
enables him to say that his mind is fully made up. 

We wish that more had been said concerning these latent cases of pneu- 
monitis. 

The crepitant rale is the earliest and most characteristic of the positive 
signs, and Dr. Flint correctly differs from Skoda, we think, in saying, that it 
is present in a very large majority of the cases of pneumonitis. 

" It is probable that examinations repeated, and made at an earlier period, 
would not have been negative as regards this sign in the greater proportion of 
the few instances in which it was not discovered. Of 149 examinations, in 
forty-five cases, made at different periods in the progress of the disease, the 
presence of the rale is noticed in eighty-five, and its absence in sixty-four. 
The collection of cases analyzed did not embrace cases of lobar pneumonitis 
occurring in infancy. My observations led me to concur with others in the 
opinion that the crepitant rale is much less constantly present in children than, 
in adults. It is perhaps opener absent than present in infant life. The con- 
stancy of the rale in acute primitive pneumonia, affecting the adult, is shown, 
by the much more extensive researches of Grisolle." P. 409. 

We should be glad to extend our notice of this book, for we have not? 
alluded to a large part of it. The chapters on bronchitis and pleuritis will 
bear much study, and from them the physician in large practice will find 
much that is valuable, much that he will recognize as true, but which he has 
not read. To do the book justice, to point out what is new, or stated in a new 
form, would require us to quote the whole book. 

In closing, we recommend the treatise to every one who wishes to become 
a correct auscultator. Based to a very large extent upon cases numerically 
examined, it carries the evidences of careful study and discrimination upon 
every page. It does credit to the author, and, through him, to the profession 
in this country. It is, what we cannot call every book upon auscultation, a 
readable book. 0. E. B.. 



Art. XI. — Statistics and Treatment of Typhus and Typhoid Fever, from 
Ticdve Years' Experience gained at the Seraphim Hospital, in Stockholm 
(1840—1852). By Magnus Huss, M. D., Professor in the Medical 
Clinic at the Caroline Institute; Member of the Boyal Academy of Science 
at Stockholm ; Laureate of the Institute of France, ete., etc. Translated 
from the Swedish original by Ernst Aberg, M. D. London : Longman, 
Brown, Green and Longmans. 1855. 8vo., pp. 200. 

The publication of the great work of Louis on the "Typoid Affection, " 
aside from its influence on clinical investigations in general, and the intrinsic 
value of its facts and results, was an important event as a point of departure 
for entering anew on the study of continued fever in different countries. 
Analyzing the phenomena faithfully recorded at the bedside, together with 
the morbid appearances noted in the dead-room, Louis established the indi- 
viduality of a disease which previously had not only been designated by dif- 
No. LXIIL— July 1856. 10 



142 



Reviews. 



[July 



ferent names, but which embraces affections that had been considered as quite 
different from each other. The form of the febrile disease so admirably eluci- 
dated, as regards its natural history, by the researches of Louis, has since been 
generally known by the title of typhoid fever. The publication of these 
researches at once gave rise to the inquiry whether continued fever in other 
countries presents the same pathological laws and lesions which had been 
found to belong to the disease in France ? It was soon ascertained by Dr. 
Lombard, of Switzerland, and our countryman, Dr. Shattuck, who, after veri- 
fying the descriptions of Louis in the Parisian hospitals, prosecuted their inves- 
tigations in the capitals of Great Britain, that the peculiar intestinal lesions 
constantly found in Paris were frequently wanting in London, Edinburgh, and 
Dublin. In the mean time, the observations of Drs. Gerhard and Pennock, 
of Philadelphia, during the prevalence of an epidemic fever among the Irish 
immigrants arriving in that city, established not only the absence in this 
« epidemic of the lesions just referred to, but the existence of striking points of 
-dissimilarity in symptomatic phenomena from those belonging to the typhoid 
.affection as described by Louis. Regarding these variations as a sufficient 
Vbasis for a nosological division, it has been customary by those who take this 
Tiew of the matter to employ the term typhus, to designate a form of fever 
(presenting certain distinctive characters first cleaily pointed out by Gerhard, 
;and since more fully studied and compared with those belonging to typhoid 
! fever, by other observers. Since the publication ot the papers by Dr. Ger- 
hard, in 1837, 1 it has been a mooted point whether a form of fever, to which 
.has been restricted the name typhus, being the predominant fever in Ireland, 
but frequently observed in other parts of Great Britain, and met with in this 
« country chiefly among Irish immigrants, should be regarded as a disease essen- 
tially distinct from the typhoid fever which prevails in France, and which has 
been shown to be an indigenous fever in certain portions of the United States; 
or whether the latter form of fever is in essence identical with the former, but 
presenting modifications due to extrinsic circumstances, or to individual pecu- 
liarities of constitution. The non-identity of typhus and typhoid fever has 
been maintained by distinguished clinical observers and medical teachers in 
this country, from the time that the point just mentioned first began to be 
mooted. This doctrine has been steadily gaining ground, and probably we 
are correct in asserting that at the present moment it is accredited by the 
majority of the well-informed members of the American Medical Profession. 
It has also been adopted for the most part by French writers. The German 
pathologists appear to hold to the identity of typhus and typhoid fever, regard- 
ing the latter as a variety of the former, and distinguished by them by the 
title abdominal typhus. In Great Britain, of late years, the unity of con- 
tinued fever has been the commonly received doctrine. It is only since the 
■ recent publication of the very valuable researches of Dr. Jenner that the non- 
identity of typhus and typhoid fever has found much advocacy with the 
.British medical press. 

The foregoing brief sketch of opinions relating to a question recently said 
.by an English reviewer to be "emphatically the question of the day," is 
: given by way of introduction to a critical notice of a work, the title-page of 
which is prefixed to this article. The object of the work, as stated in the 
preface, is to present the results of the scientific experience acquired from the 

1 American Journal of the Medical Sciences, vol. xix., p. 239. It is clue to the 
memory of the late Dr. Hale, of Boston, to state that in an account of the fever of 
Massachusetts, published in 1839, he foreshadowed, as it were, the distinctions between 
typhus and typhoid fever. 



1856.] 



Huss, Typhus and Typhoid Fever. 



143 



author's connection for a period of twelve years, with a hospital which re- 
ceived during that time more than 3000 cases of continued fever. These 
cases, it may be here remarked, were not all under the observation of Prof. 
Huss, a proportion of about one-fourth coming under the charge of his col- 
league, Prof. Malmsten. A small proportion only were recorded and sub- 
jected to analysis, viz : 250 cases which occurred during the last months of 
1843 and the beginning of 1844. The histories of these cases were obtained 
with the aid of several medical attendants at the clinic, who at that time were 
students' of medicine, but in whose accuracy and fidelity the author had full 
confidence. It is proper to cite these statements as tending to show the 
nature and extent of the author's experience, the more so because it will be 
seen that the conclusions purporting to be derived from it do not in all re- 
spects accord with those based on observations made in other parts of Europe 
and in America. 

The name of Prof. Huss will to man}' of our readers not be new. He is 
known by his previous publications on the diseases of Sweden, and especially 
by his description of certain effects of the abuse of alcohol, under the title of 
acoholismus chronicus. In a late publication 1 he is referred to as a a most 
philosophical, practical-minded physician, standing deservedly at the head of 
the profession in Northern Europe. " 

The work proper is devoted to the statistics and treatment of typhus and 
typhoid fever. In the introduction to the work, however, Prof. Huss de- 
clares his belief in the identity of typhus and typhoid fever, and states the 
grounds on which this opinion is founded. Now, the importance of the sta- 
tistics which occupy a considerable portion of the volume, in a great measure 
depends on the correctness of this doctrine of the identity of these two forms 
of fever. The cases received at the Seraphim Hospital in Stockholm in all 
probability embraced cases of typhus and typhoid fever, as these terms are 
now generally applied. Prof. Huss regards these two forms of fever as 
essentially one disease, and accordingly his statistical researches and thera- 
peutical conclusions for the most part have reference indiscriminately to both 
forms. Let it be admitted that typhus and typhoid fever are distinct affec- 
tions, and the deductions from his experience it is clear cannot be applied to 
either affection to the exclusion of the other, more than the results of an in- 
vestigation collectively, of a series of cases of rubeola and scarlatina could 
be made available either for extending or giving greater precision to our 
knowledge respectively of these different eruptive fevers. The value of 
Prof. Huss' work as contributing facts pertaining to the natural history of 
typhus and typhoid fever, thus hinges on the mooted point stated in our 
introductory remarks. We propose, therefore, to notice at some length the 
grounds adduced by Prof. Huss for his belief in the identity of typhus and 
typhoid fever. We propose to do this, not because the arguments are new, 
nor because they have not been already satisfactorily refuted; but the 
author claims that his opinion is founded on a long and extensive clinical 
experience, and it is due to him as well as to the importance of the subject, 
to institute a critical examination of the evidence which he offers in support 
of this opinion, while others, in different countries, who have carefully 
studied continued fever at the bedside, have arrived at a different conclusion. 

Before entering on the discussion of the question of the identity or non- 
identity of typhus and typhoid fever, let us clearly understand the point 
concerning which opinions are divided. By those who take the ground of 



1 Transactions of American Medical Association, vol. viii. p. 583. 



144 



Reviews. 



[July 



identity, it is not denied that certain cases of continued fever are characterized 
by the symptoms and lesions belonging to typhoid as distinguished from 
typhus. The question relates not so much to facts as to the inferences 
from facts. We shall presently see that Prof. Huss bears testimony to 
many of the facts upon which rests the doctrine of non-identity. But it is 
contended that the characteristics of typhoid fever, as contrasted with those 
of typhus, instead of denoting an intrinsic difference in the disease, proceed 
from extrinsic circumstances pertaining to season, place, individual peculiari- 
ties, and variations in epidemic influences. On the other hand, the advo- 
cates of non-identity contend that the points of dissimilarity in the natural 
history of the two forms of fever are of a nature not to be thus disposed of; 
that the distinctive features of either form show an essential difference inhe- 
rent in the disease ; and, hence, that the two forms are different diseases. 
Now on what conditions does the individuality of a disease depend? With 
our present knowledge of pathology and etiology, it is rarely the case that 
we are able to discriminate different affections after what we positively know 
of their essential nature or their special causes. We should be able to do 
this were medical science perfect. As it is, our nosological divisions are of 
necessity based on logical inference, not on demonstration. Many diseases 
which are justly regarded as essentially distinct, have not a few phenomena 
in common. This is true of all the essential fevers. Take rubeola and 
scarlatina for example ; they often bear to each other a close resemblance, 
and, in fact, it is only in modern times that they have been nosologically 
separated. Why do we now regard them as different diseases ? Clinical ob- 
servation has shown that they are respectively characterized by. certain pecu- 
liarities which each preserves with such constancy that the existence of dis- 
tinct pathological laws may be thereon predicated. An eruption belongs to 
each. This eruption, although in both an efflorescence, is found to present certain 
features as respects sensible characters, the time of its appearance, its diffu- 
sion over the body, and its immediate effects, which are as uniformly in con- 
trast in the two diseases as they are in accordance in successive cases of the 
same disease; hence they denote the existence of different laws in the two 
affections. In scarlatina, the pharynx is the seat of an inflammatory pro- 
cess; a catarrhal affection of the mucous membrane lining the air-passages, 
enters into the natural history of rubeola. The laws determining the ana- 
tomical characters of the two diseases are thus different. Both affections are 
contagious; but the miasm emanating from the body of a patient affected 
with scarlatina never gives rise to the phenomena which characterize rubeola, 
but invariably to those which belong to scarlatina, and vice versa. Hence it 
is certain that the special cause which produces each affection is peculiar to 
it. Moreover, when a patient has experienced either affection he is ren- 
dered thereafter, as a rule, exempt from its recurrence; but having passed 
through one furnishes no exemption for the future against the other. These 
facts, established by clinical observation, are sufficient to show that whatever 
may be the phenomena which are common to scarlatina and rubeola, the two 
affections are not merely varieties of the same species of disease, but are in- 
trinsically and essentially distinct from each other, albeit the precise nature 
and extent of the difference, owing to the imperfection of medical science, 
cannot be defined. If in the several points of view in which scarlatina and 
rubeola have just been contrasted, clinical facts lead to a contrast not less 
striking between typhus and typhoid fever, can there be any reasonable 
ground for denying that, in the same sense, they are distinct diseases; in 
other words that they are non-identical ? 



1856.] 



Huss, Typhus and Typhoid Fever. 



145 



Proceeding to review the grounds on which Prof. IIuss founds the conclu- 
sion that typhus and typhoid fever are identical, or, as he expresses it, " dif- 
ferent varieties of one and the same pathological process/' the first point 
referred to is the concurrence of cases of both forms during the same epi- 
demic. We quote his remarks under this head. 

" I have endeavoured to follow -with attention two rather considerable epi- 
demics of typhus, one of which commenced in September, 1841, and continued 
until July, 1842, the other in December, 1845, to July, 1846. 503 typhus pa- 
tients were received in the wards of the Seraphim Hospital during the course 
of the former, 414 during the latter epidemic. In neither instance were the 
cases exclusively typhus or typhoid fever, on the contrary there were some of 
both ; so that in the beginning and to the height of the epidemic the cases 
were for the most part typhus, and at the end the typhoid fever almost entirely 
prevailed. This statement is founded not merely on the symptoms each indi- 
vidual case presented, but also on the results of the post-mortem examinations. 
With the exception of four, all who died were examined ; there were 55 fatal 
cases in the former epidemic, 33 in the latter; of the former 55, 36 presented 
those alterations of the intestinal tube and mesenteric glands, which are 
peculiar to typhoid fever, and 19 no such alterations ; of the latter 33, only 29 
were examined ; of these, in 19 the glands were changed in different degrees, 
the remaining 10 showed no change." Page 7. 

The author adds in a note that another epidemic, in 1852, had every cha- 
racter of the exclusively abdominal form (typhoid), all the post-mortem ex- 
aminations, with the exception of one only, exhibiting the usual changes in 
the intestinal glands. 

The simultaneous prevalence of typhus and typhoid is a matter of frequent 
observation : on this point Dr. Jenner remarks, "a fact which has greatly 
contributed to typhus and typhoid fever being confounded is that often both 
prevail at the same time, similar circumstances favouring their propagation, 
the miasm of both appearing to be subject to the same laws of evolution, so 
that whenever one prevails the other will be likely also to prevail. This will 
serve to explain the contradictions which apparently exist in the descriptions 
of camp and jail fever, to be found in the works of old authors as well as in 
those of our own day." 1 In certain situations, for example in Paris, and in 
certain portions of our own country, typhoid fever is the species which exclu- 
sively prevails, and cases of typhus are not expected, of course, to occur ; but 
wherever typhus prevails, cases of typhoid fever are frequently, if not gene- 
rally intermingled in greater or less proportion. This is verified by observa- 
tions at London, Dublin, and Edinburgh. In our own experience during 
several years that we were engaged in studying clinically the two fevers, 
cases of each were at the same time under observation, sometimes those of 
typhoid fever, and at other times those of typhus predominating, the cases of 
both occurring for the most part among foreign immigrants from Ireland and 
Germany. 

It is simply a matter of fact that both typhus and typhoid fever may pre- 
vail at the same time and place. Certainly, in itself, the fact proves nothing 
with respect to the identity of the two affections. The author himself does 
not attach much importance to the fact, candidly saying, " experience tells 
us that two epidemic diseases may appear simultaneously at the same place; 
for instance, scarlet fever and the measles ; nay, it has been said that the 
two diseases may occur at the same time in the same person." 

1 It is proper to state that in making quotations from the writings of Dr. 
Jenner, a French translation is resorted to, copies of his publications in English not 
being accessible to the reviewer during the preparation of this article. 



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A vastly stronger point would be to show community as respects the spe- 
cial causes of the two affections. Will the same miasm produce indifferently 
typhus and typhoid fever ? When propagated by contagion, is typhus found 
to follow exposure to the miasm emanating from the bodies of typhoid pa- 
tients, and vice verm? If the affirmative to these questions were to be 
proved, assuredly it would go far to establish the identity of the two forms 
of disease ; and, on the other hand, proof of the negative is not less direct 
and cogent in behalf of their non-identity. ' The author cites two instances 
in which both forms of fever were supposed to spring from the same source. 
We quote the account of each instance in full. 

"A man had died, it was t stated, of typhus. The brother and his wife went 
to live in the house of the deceased, and used his clothes without previous air- 
ing and cleaning; they were soon taken ill and brought to the hospital, where 
they both died. The husband had violent delirium and a profuse petechial 
eruption, the post-mortem examination showing no change of the intestinal 
glands ; the wife had milder cerebral symptoms and a very scarce crop of 
eruption; but on examination swollen mesenteric glands and swollen and 
ulcerated Peyer plagues were found in abundance." 

We have italicised the evidence which this account affords that the pri- 
mary case was typhus, although perhaps this is not of much moment so far 
as concerns the argument. The account is defective in other important de- 
tails. How long after taking possession of the house and wearing the clothes 
of their deceased kinsman, were the husband and wife attacked ? Were they 
attacked simultaneously or successively, and, if the latter, after what interval 
of time? Did typhus or typhoid fever, or both, prevail at that period? 
These inquiries have obvious bearings on the inference to be drawn from the 
facts stated. The husband, it appears, had typhus fever, and it is presumable 
that the infected clothes were worn by him alone, inasmuch as the deceased 
kinsman whom it was said had died of typhus, was of the male sex. So far 
the facts favour the doctrine of the non-identity rather than that of the iden- 
tity of the two forms. The development of typhoid fever in the person of 
the wife may have had no connection with the occurrence of the cases of 
typhus. So far as details are given, it is fair to suspect, to say the least, 
that the concurrence or succession of the two cases of the different forms of 
fever in this instance was due to coincidence, in other words accidental. 
This suspicion is, of course, the more allowable if (what is undoubtedly true) 
the facts given in the foregoing account are exceptions to a general rule. 

The other instance was communicated by a medical practitioner in the 
country, and is as follows : — 

" A traveller came to a small island situated on the western coast of Sweden. 
He was sick when he arrived, and was the same day laid up with a fever. The 
disease showed all the marks peculiar to typhus petechialis, viz : clearly 
marked alteration of the blood, and a very copious typhus eruption (ecchy- 
motic petechias), and ended on the ninth day fatally. Seven persons were 
successively taken ill on the island ; only one of these presented the marks 
characterizing typhus ; the remaining six cases, of which one was fatal, were 
all clearly distinct typhoid. The course of this limited epidemic made it evi- 
dent that it was produced by infection from the first diseased person who came 
ill, before whose arrival no case of typhus or typhoid had been seen for several 
years, either on the island or in the neighbourhood, and that the same conta- 
gion produced both typhus and typhoid fever." 

We have the same objection to bring against this as against the preceding 
account, viz: it is deficient in important details. The imported case was 
held to be a case of typhus in consequence of an alteration of the blood, and 



1856.] 



Huss, Typhus and Typhoid Fever. 



147 



an eruption of eccliymotic peicch'se. What the evidence was of an alteration 
of the blood peculiar to typhus we are left to conjecture. From the terms 
used to indicate the character of the eruption, there is room for a strong sus- 
picion that it consisted of true petechias, i. e. minute extravasations, which are 
widely different from the characteristic maculae of typhus, and by no means 
peculiar to the latter fever. Of the subsequent cases all but one were re- 
garded as typhoid. The excepted case did not prove fatal, so that the evi- 
dence of its being a case of typhus rests solely on the phenomena during life. 
No description of these phenomena is given. The reader must rely exclu- 
sively on the judgment of the observer, and inasmuch as not a single case of 
either species had been known to occur on the island for several years before, 
it is not unfair to entertain some distrust of the ability of the practitioners 
residing there to discriminate practically between the two fevers. At all 
events, the evidence of the statements made in the report of the country prac- 
titioner is inadequate to secure for them any weight in opposition to well 
ascertained facts from which other conclusions are deducible; especially when 
it is considered that, in all probability, the observations were made under the 
bias of belief in the identity of typhus and typhoid fever. 

With the researches of Dr. Jenner on the non-identity of the special 
causes of the different forms of continued fever, we presume many of our 
readers are familiar. Professor Huss could not have been acquainted with 
them, else he would hardly have attached much importance to the unsatisfac- 
tory, and, we may add, unscientific reports which have just been quoted. Dr. 
Jenner took pains to trace to their respective localities all the cases of con- 
tinued fever received into the London Fever Hospital during the years 1847, 
1848, and 1849. In 1848, one quarter of all the fever patients received 
into the hospital were affected with typhoid fever; and out of forty-four 
localities which furnished one hundred and one typhus cases, there was but 
a single instance in which one patient affected with typhus, and another 
affected with typhoid fever, came from the same house. Of five localities, 
which during the same year furnished nine cases of typhoid fever, the 
same statement holds good. In 1849, fifty-one typhus patients came from 
eighteen localities, and ten typhoid patients from four localities. During this 
period in no instance did the same house furnish a case of each fever. This 
rule was found to exist without an exception in 1847; but the number of 
cases traced in this way to their source was less during this year than the 
two following years. 

We look upon these results of the researches of Dr. Jenner as very valua- 
ble, showing the nature of the special causes producing typhus and typhoid 
fever to be not identical, and, inferentially, the non-identity of the diseases 
themselves. 

In a single instance among the large number collected by Dr. Jenner, in 
which two or more patients were traced to the same habitation, it was found 
that one house had furnished a case of typhus and a case of typhoid fever. 
This shows that the rule is not without exceptions. Prof. Huss, as we have 
seen, adduces an exceptional instance. He cites it in proof that the special 
cause is the same in both fevers — overlooking, however, the importance of 
either establishing or disproving the rule of which the instance cited was an 
exception. 

The most rational explanation of these exceptions is to attribute them to 
mere coincidence. With reference to scarlatina and measles, we can cite a 
curious occurrence, which no one will doubt was purely accidental, but which, 
taken alone, would go to show identity of the contagious miasm producing 



148 



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these two diseases. In a family embracing two children (girls), one aged 
seven, and the other four years, the latter was attacked with rubeola March 
28. Measles were prevalent at , the time, but it was not known that the child 
had been exposed to the contagious miasm of this disease. On the 5th of 
April medical attendance was discontinued. On the 28th of April the sister 
was attacked with scarlatina, and was convalescent on the 9th of May. The 
histories of both cases were recorded. There had been no known exposure 
to the contagion of scarlet fever, and the child had never had measles. The 
exposure to the contagion of the latter disease, during the illness of her sister, 
was as complete as possible. We give this simply as an illustration of the 
risk of drawing inferences from isolated instances. As regards the point 
under consideration, the argument for or against the identity of typhus and 
typhoid fever is to be based on the law which regulates the causation in the 
vast majority of cases. If we may logically conclude that the special cause, 
whatever it may be, or whence derived, of typhus, is peculiar to it — i. e., that 
it never gives rise to typhoid fever — and conversely with respect to the spe- 
cial cause of the latter, it must be admitted to constitute a very cogent argu- 
ment in favour of the non-identity of these affections. The facts developed 
by the researches of Jenner appear to warrant such a conclusion, but it is 
undoubtedly desirable that the same method of examination should be still 
further prosecuted. 

Prof. Huss states as a ground for his belief in the identity of typhus and 
typhoid fever that they are often with difficulty discriminated from each other; 
and, indeed, he asserts this to be in many instances utterly impossible. He 
also declares that intermediate forms are of frequent occurrence; in other 
words, the features said to characterize each form may be variously intermin- 
gled. The latter point he considers with reference to some details to which 
we shall presently advert. 

These statements are opposed to the results obtained by a careful study of 
the two fevers in other countries. Their characteristic phenomena are found 
to be singularly constant, bearing numerically about the same ratio in the 
relative frequency of their occurrence in widely separated situations. The 
results of the analyses of recorded histories of typhoid fever in Paris, London, 
and in America, present few discrepancies. The same is true as respects 
England and America of typhus fever. For proof of the correctness of this 
position we refer the reader to the statistical researches of Louis in France, 
Jenner in London, Jackson and Flint in different parts of this country. 
Evidence is afforded in the publications just referred to of the fact that, in 
the same situation, in successive years, these diseases maintain a remarkable 
uniformity in their phenomena and laws. We have shown this to be the 
case by bringing into comparison the results of three distinct analyses, made 
in three successive years, of separate collections of histories gathered during 
these years. 1 So far from the statement of the author respecting the diffi- 
culty of discriminating clinically the two diseases from each- other being in 
accordance with our experience and that of others, we should say that the 

1 Vide Clinical Reports on Continued Fever, etc. Dr. Jenner' s testimony on this 
point is explicit. He says: "During tbe three years that nearly all the patients 
admitted into the London Fever Hospital were the subjects of careful observation, I 
did not discover any variation in the symptoms, general or local, either in the cases 
of typhus or in those of typhoid fever; notwithstanding that there prevailed during 
this period epidemics of relapsing fever, of typhus and cholera, denoting different 
modifications of the epidemic constitution." — On the Non-identity of Typhus and Ty- 
phoid Fever, Bruges, 1853, p. 164. 



1856.] 



Huss, Typhus and Typhoid Fever. 



119 



cases are rare in which a physician, accustomed to observe both, need hesitate 
in arriving at a diagnosis. Dr. Jenner remarks, that even the hospital nurses 
at the London fever hospital are seldom at fault in distinguishing between 
the two fevers,- and on being asked by the attending physician whether any 
new cases have been admitted since the last visit, they say without hesitation, 
" Yes, a case of typhus/' or typhoid, as the case may be. We can make the 
same remark. The intelligent sister of charity who had charge of the fever 
ward at the hospital in which our histories were mostly collected, was accus- 
tomed to designate cases as typhus or typhoid with almost uniform cor- 
rectness. 

In view of the learning and experience of Prof. Huss — according to him, 
as we are bound to do, sincerity in his statements — how are the latter to be 
reconciled with the opposite conclusions at which other clinical observers have 
arrived? We may suppose that the signa diognostica of typhus and typhoid 
fever are uncertain in Sweden, although sufficiently reliable elsewhere. This 
is not probable, inasmuch as these affections are found to retain their distinc- 
tive traits, as has been seen, in different and widely separated countries. 
Moreover, we confess that we are skeptical as regards extensive modifications 
of disease by climatic influences. We do not by any means deny that modi- 
fications may proceed from this source, but there is reason to believe that 
diseases vary much less than it has been customary to imagine. We look 
upon the notions commonly held on this subject in somewhat the same light 
as we do the opinion so often uttered, that certain affections will not of late 
years bear the same measures of treatment which were formerly demanded. 
The true explanation of this opinion we believe is, that it is so difficult to 
determine with precision the success of therapeutical measures, and accord- 
ingly it was perhaps less in past time, or at the present time, than it suits our 
self-complaisance to suspect. In other words, the opinion is simply founded 
on the fact that our present views of treatment differ from those formerly 
practised. So with regard to the phenomena and laws of diseases; they are 
thought to fluctuate much more than they do, because the natural history of 
but few diseases is as yet settled by means of analyses of a sufficient number 
of recorded cases. Judging from the extent to which those affections that 
have been most studied are found to preserve their individual characters un- 
changed in different seasons and places, it may be anticipated that a more 
complete knowledge of the phenomena and laws of different diseases will be 
likely to lessen the importance which, since the time of Sydenham, has been 
attached to the " constitution of the year." 

Another, and we are forced to conclude a truer, mode of accounting for 
the views of Prof. Huss, is derived from the fact that he has not taken pains 
to record and analyze cases of both forms of fever separately, bringing the 
results into contrast with each other ; nor does it appear from his work that 
the researches of others within late years, conducted after this plan of inves- 
tigation, have fallen under his notice. His convictions are based on unre- 
corded experience, not on conclusions educed by analysis from facts noted at 
the bedside. The statistics to which a considerable portion of the volume is 
devoted, as already stated, relate to both fevers indiscriminately. 

The characters and laws pertaining to the eruption in typhus and typhoid 
fever are of great importance, not only with reference to the differential diag- 
nosis, but as affording evidence of non-identity. The lenticular rose-coloured 
eruption in typhoid cases, as regards its sensible characters, differs in several 
striking particulars from the maculated eruption, called by Jenner the mul- 
berry rash, or, as it is frequently but with doubtful propriety designated, the 



150 



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[July 



petechial spots belonging to typhus. Prof. Huss does not enumerate the fea- 
tures regarded as distinctive of the two fevers by those who hold to the doc- 
trine of non-identity ; he assumes that they are well known to others as well as 
to himself, and asserts that he has frequently observed the typhus and typhoid 
eruptions to become developed simultaneously, and also the former, not un- 
commonly, to appear first and disappear, the latter taking its place. Here 
his experience is at variance with the results of analyses of large collections 
of cases in which, by different observers, the appearances have been carefully 
noted day after day at the bedside during the whole career of the disease. 
What is to be said of the above assertions of the Swedish professor ? 
Frankly, we must avow that, without impeaching his honesty, we cannot give 
credence to his statements. Inasmuch as he does not profess that they are 
based on other data than those which the memory is capable of retaining, we 
must believe him to be mistaken unless we adopt the improbable hypothesis, 
that the phenomena and laws of these diseases are widely different in Sweden 
from those established by recorded observations in other countries. A fair 
examination of the difficulty, nay, the impossibility of recollecting the facts 
pertaining to a series of cases sufficiently for accurate deductions, would justify 
the disbelief just expressed, especially when belief involves a repudiation of 
results obtained by different observers, without concert, who have resorted to 
a method of investigation requiring much care and patience, but which has 
the recommendation of being in a great measure free from the liability to error 
incident to the weakness and imperfection of the mental faculties. 

We do not wish to be understood as contending that the two eruptions never 
present any variations in their distinctive appearances. These appearances 
are more strongly marked in some cases than in others. In a few of the 
typhus cases which we have recorded, with the characteristic maculse were 
intermingled others bearing more or less resemblance to the taches rosees, but 
the predominant character of the eruption was unmistakable. Dr. Jenner 
points out certain changes which the typhus eruption undergoes in different 
stages of the disease which may possibly have led, in some instances, to the 
error of supposing that the two kinds of eruption are frequently found in com- 
bination. He states, that at first the spots have a rose hue, are slightly 
elevated, and the redness disappears momentarily on pressure, but they acquire 
soon the dusky hue, lose their elevation, and only become paler on pressure. 1 
The variations, however, in sensible characters which are observed in different 
cases of typhus and typhoid fever, are not greater than in all the eruptive 
fevers, for example, in scarlatina and rubeola. The scarlatinous eruption 
varies in colour, and sometimes assumes the form of minute isolated dots 
instead of being diffused, or presenting irregular patches of greater or less 
size. The appearance of the eruption in measles is not less variable. But, 
notwithstanding these diversities, the distinctive traits belonging to each are 

1 In nearly all of the few instances among the cases recorded by the writer, in which 
the eruption presented mixed characters, this peculiarity was observed during the 
early part of the eruptive period. Prof. Huss curiously makes a statement directly 
the reverse of that by Dr. Jenner referred to above. He avers that it is not uncommon 
for an eruption of petechias to occur during the first four or six days, which disappear 
after the lapse of two or three days and gives place to the lenticular spots. He says, 
the primary petechial eruption is " sometimes of a bright and sometimes of a more 
dusky red," but " very seldom ecchymotic." In another place he defines the typhus 
eruption to be "ecchymotic petechias." The language just quoted suggests a doubt 
whether the author has a clear idea of the distinctive characters of the two eruptions. 
He should have guarded against this doubt by describing the appearances of the erup- 
tion. This is an omission to which the reader has a right to take exceptions. 



1856.] 



Huss, Typhus and Typhoid Fever. 



151 



very rarely, if ever, so confused that it becomes difficult to distinguish the one 
affection from the other by the sensible characters of the eruption alone. 
This statement we believe to be not less applicable to the cases of typhus and 
typhoid fever, in which an eruption is developed. But, in these fevers as in 
those of the eruptive class, for example, scarlatina and rubeola, the circum- 
stances pertaining to the eruption which furnish diagnostic criteria, by no 
means relate solely to the sensible characters. The eruption appears earlier 
in typhus than in typhoid, the former, in this respect, sustaining a relation to 
the latter similar to that of scarlet fever to measles. In typhoid fever spots 
successively appear, taking the place of others which disappear during the 
eruptive stadium ; in typhus the spots once developed are permanent during 
the period of the eruption. In cases of typhoid fever which prove fatal while 
the eruption is present, no traces of the spots are discovered after death; while 
in cases of typhus the eruption is observable on the cadaver. These facts 
not only furnish means of discrimination, but have an important bearing on 
the question of identity. If observation have established that the eruption in 
typhus and typhoid fever differs not only in obvious sensible characters, but 
as respects the laws regulating the time of its appearance, the mode of its 
perpetuation, and its duration ; does not this, in itself, constitute sufficient 
ground for regarding the two affections as non-identical in the same sense in 
which scarlatina and rubeola are considered as distinct diseases? 

Next in importance to the distinctive characters pertaining to the eruption, 
are the intestinal lesions peculiar to typhoid fever and the abdominal symp- 
toms therewith connected, in their bearing on the question under discussion. 
In fact, the latter are, perhaps, even more important than the former in this 
relation. Both, however, are to be taken conjointly in the endeavour to 
determine whether typhus and typhoid fever are identical or not. Are cases 
which are characterized by a well-marked typhus eruption, as well as by other 
traits peculiar to this fever, as a rule wanting in certain abdominal symptoms, 
viz : diarrhoea, meteorism, tenderness in the iliac fossae, and gurgling, which 
are observed in the great majority of cases presenting the characteristic typhoid 
eruption; and in fatal cases are the Peyerian patches and mesenteric glands 
found on dissection to be very slightly or not at all affected ; if the eruption 
and other symptoms have denoted typhus, while notable lesions in these parts 
are as constantly discovered, provided the eruption and abdominal symptoms 
have indicated typhoid fever? If the affirmative be proved, then, in addition 
to the different laws governing the eruption which have been referred to, other 
laws determining a marked difference in anatomical characters are established ; 
a difference certainly greater than that which exists between scarlatina and 
rubeola. We must presume our readers to be familiar with the typhoid 
intestinal lesions, which, although not unobserved prior to the researches of 
• Louis, were by him more fully described than by any previous observer, and 
their significance as an anatomical characteristic of a species of fever first 
pointed out. The absence of these lesions was tke grand negative point of 
distinction, so far as relates to morbid anatomy, developed by the investiga- 
tions of Gerhard and Pennock, which have resulted in establishing, as we 
think, the individuality of typhus and its essentially distinct nature. The 
facts contributed during the few past years by observers in different countries, 
to the elucidation of the points involved in the above inquiry, the reader is also 
supposed to be acquainted with. If not, we must refer to publications already 
mentioned. We could not reproduce them here in any detail without exceed- 
ing the limits appropriate to this article. Suffice it to say, that the analysis 
of a host of cases collected in different quarters of the world, the recorded 



152 



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[July 



histories embracing the appearances found after death, and the phenomena 
noted during life, have shown, on the one hand, constancy of connection 
between the eruptive and other symptomatic characters peculiar to typhoid 
fever and the so-called typhoid intestinal lesions; and, on the other hand, 
absence of these lesions when the eruption and other symptoms were unequivo- 
cally those which belong to typhus. This can be said in behalf of the non- 
identity of typhus and typhoid fever. Now can the advocate of their identity 
assemble from any or all authentic sources a group of fatal cases in which, 
the data being in like manner placed on record, the eruptive and other symp- 
tomatic characters of typhus were found to be associated with the typhoid 
intestinal lesions, or, conversely, in which the eruption and other symptoms 
of typhoid fever were present, and these lesions found to be wanting ? It is 
now twenty years since the uniformity of certain intestinal lesions in well- 
marked cases of typhoid fever, and their uniform absence in cases' of typhus 
began to be mooted. During this time the amount of positive evidence in 
support of these positions has been constantly accumulating, while there have 
been ardent advocates, as there are still, of the identity of the two fevers. It 
would obviously go far toward establishing the correctness of the latter doc- 
trine were these positions to be disproved. Have there been any sufficiently 
authenticated instances reported in which typhoid lesions have been found 
when the diagnostic criteria of typhus were clearly present during life ? 
This question, in fact, covers the whole ground, for the occasional absence of 
these lesions in well-marked typhoid cases would not invalidate their relation- 
ship to the disease more than the absence of the eruption or the throat affec- 
tion in some cases of scarlatina is sufficient to impair their significance, when 
present, as criteria of this fever. In an able and candid article, published in 
1851, in the British and Foreign Medico- Chimrgical Review, the writer cites 
as the only instances which had been offered, up to that time, of the typhoid 
lesions having been found in well-marked typhus cases, those reported by M. 
Landouzy in the Archives Generates de Medecine. 1 

These cases were observed during the prevalence of an epidemic in the 
prison in Rheims, in 1839-40. They have been often referred to in discus- 
sions of the subject under consideration. A critical examination, however, 
of the facts as they are reported by M. Landouzy, divests them of any value 
in their bearing on the identity of typhus and typhoid fever. 

It appears not only as an inference from the histories of the cases, but 
from the statements of Landouzy himself, that both typhus and typhoid fever 
prevailed at Rheims when his observations were made. Of the fatal cases, 
six only were examined, and the morbid appearances recorded in but two 
instances. In one of the latter the eruption and other symptoms were un- 
doubtedly those which are distinctive of typhus. The evidence in this case 
of the existence of typhoid lesions is not only insufficient, but from the de- 
scription it is almost certain that they were not present. The small intes- 
tines were pronounced healthy by three physicians who examined them ; but 
M. Landouzy "detected what he considered evidence of an incipient change 
in Peyer's patches, with general slight tumefaction of the solitary glands." 2 
The appearances, if morbid, were in all probability those which are fre- 
quently seen in cases of typhus, consisting merely in moderate or slight 
hypertrophy, with perhaps the " shaven-beard" aspect. 3 The fact that the 

1 Vol. xii. pp. 1 and 306. 

2 We are indebted for these facts to the article in the British and Foreign Medico- 
Chirurgical Review already referred to. 

3 Our observations lead us to concur with Dr. Jenner in regarding the appearance 
thus designated as not distinctive typhoid fever. 



1856.] 



Huss, Typhus and Typhoid Fever. 



153 



patches of Peyer are not entirely unaffected in typhus fever we have endea- 
voured to impress in connection with our own researches. It is a fact not to 
be lost sight of, but it does not diminish in the least the significance of the 
true typhoid lesions, which are so different from the alterations just men- 
tioned that the contrast is scarcely less than if the patches were never in the 
least degree altered in typhus. The morbid deposit, softening, sloughing, 
and ulceration, are peculiar to typhoid fever. 

In the second case, the evidence of the characteristic typhoid lesions was 
complete, but the ante-mortem history in this case renders it pretty certain 
that the disease was typhoid fever. The eruption consisted of rose spots, 
intermingled with others which resembled flea-bites; and whereas the latter 
bear little or no resemblance to the maculae of typhus, they were probably 
either veritable flea-bites or an eccentric variety of the taches rosees. 

Since the publication of these famous cases of M. Landouzy, which, if 
they prove anything, go rather to support than invalidate the doctrine of 
non-identity, the importance of discovering instances in which the typhus 
phenomena during life are found to be associated with the typhoid lesions has 
certainly not been less than previously; but if such instances have been 
reported they have not fallen under our notice. 

In the foregoing remark, I do not refer, of course, to loose general state- 
ments made by physicians who may have seen more or less of typhus and 
typhoid fever, but who do not take pains to record their cases, and compare 
the phenomena noted during life with the postmortem appearances. The 
evidence in behalf of the constancy of the relation between the typhoid 
lesions and the diagnostic criteria of typhoid fever is based on cases, the his- 
tories of which were noted at the bedside, and it is but fair to require the 
same condition in admitting opposing evidence. It is sometimes asserted by 
practitioners that they have found the typhoid lesions in cases presenting 
during life the phenomena of typhus; but in view of the mass of facts which 
render this assertion improbable, we have a right to call for proof that there 
has not been an error of diagnosis; and this proof to a non-observer of the 
cases can only be afforded by their fully recorded histories. Taking this 
ground we shall find no difficulty in disposing of the statements of Prof. Huss 
relative to the point under consideration. He says : — 

"We find, as a rule, the changes of the intestinal and mesenteric glands 
wanting in the graver forms of typhus petechialis, but, as exceptions, enlarge- 
ment sometimes both of the solitary and Peyerian glands. It has, however, 
by no means been uncommon to see as well enlarged glands as spread ulcera- 
tions in milder cases, although with a distinctly pronounced petechial erup- 
tion." 

Now, in accordance with the views which we have just expressed, we feel 
•justified in attaching little or no importance to the author's assertion respect- 
ing the occurrence of exceptions to the general rule, notwithstanding his 
experience. The statement is not based on a comparison of the phenomena 
recorded during life, and the appearances noted in the dead-room. He does 
not profess to have made such a comparison. No evidence appears in the 
portion of the volume devoted to statistics that even the 250 cases whose his- 
tories were noted, with the help of five medical students, were analyzed with 
reference to the relation existing between the symptoms and intestinal lesions. 
We therefore deem it perfectly fair to assume that in the exceptional cases of 
the graver forms of typhus petechialis in which enlargement of the Peyerian 
and solitary glands were discovered after death, the morbid alterations did 
not exceed those which undoubtedly do occur in typhus as already men- 



154 



Reviews. 



tioned; and that the author is mistaken in asserting ulcerations to have been 
found in milder cases in which a distinctly pronounced petechial eruption 
existed. 

As already stated, Prof. Huss does not appear to have examined those of 
his recorded cases which proved fatal, in order to determine whether intes- 
tinal lesions were found in typhoid cases and in these cases only. His sta- 
tistics, however, embrace certain data which will enable us to form, approxi- 
matively, conclusions with respect to these points. We will avail ourselves 
of these data, and endeavour to ascertain whether his facts are consistent 
with the statements of which we have just expressed an opinion. Of the 
250 cases which are analyzed, an eruption was observed in 192. In 51 of 
these 192 cases the eruption is stated to have been petechial, and in 141 
lenticular or typhoid. The ratio of the former is, then, a fraction below 26, 
and of the latter a fraction over 73 per cent. Now, we will assume that the 
cases with the petechial eruption were cases of typhus, and those with the 
lenticular eruption were cases of typhoid fever. This being assumed, on the 
supposition that in typhus cases the intestinal lesions were wanting, while 
they were present in the typhoid cases, it follows that these lesions existed in 
73-100, and were absent in about 27-100 of the whole number, viz. 192. 
How do these results compare with the relative proportion of instances 
among the fatal cases examined after death, in which the intestinal lesions 
were, on the one hand, present, and, on the other hand, absent? The num- 
ber of fatal cases, all of which were examined after death, was 25. Of this 
number the Peyerian glands were found more or less affected in 72-100, and 
unaffected in 28-100. Thus it appears that the ratio of instances in which 
a petechial eruption was noted, compared with the ratio of instances in which 
the Peyerian glands were unaffected, is as 27-100 to 28-100; and the ratio 
of instances in which intestinal lesions existed compared with the ratio in 
which the typhoid eruption was noted, is as 72-100 to 73-100. 1 In these 
calculations, we assume the number of fatal cases of both forms of fever to 
be equal. To this the author cannot take exceptions, as he does the same in 
determining approximatively the proportion of cases of petechial and abdo- 
minal typhus in the hospital cases not noted. It is evident, however, that 
the mortality in the two forms of disease may not have been the same, and 
perhaps the disparity in this respect may account for the small variation in 
the numerical results in the comparisons just made. 

These results, to say the least, render it highly probable that had the 
author taken pains to have ascertained, in the 25 fatal cases, from the re- 
corded histories, whether those in which intestinal lesions existed were cha- 
racterized by the typhoid eruption, and, per contra, whether those in which 
the lesions were absent presented the typhus eruption — an undertaking not 
very laborious — he would have found that his opinions were disproved by his 
own facts. We cannot forbear expressing astonishment that it did not occur 
to him to institute such an examination. In the 250 recorded cases, 25 of 
which proved fatal and were examined after death, he had the data for test- 
ing, on a limited scale, the correctness of the opinions to which it is suffi- 
ciently clear his mind was committed prior to collecting these histories. 
Instead of doing this — a w r ork of an hour or two — -he contents himself with 
an enunciation of his opinions purporting to be based on his unrecorded ex- 
perience. From this, as well as from the general tone of the work, it would 



1 The correspondence in the amount of difference in the two comparisons is worthy 
of notice. 



1856.] 



Huss, Typhus and Typhoid Fever. 



155 



seem that the analytical method of clinical investigation is either but little 
known, or imperfectly appreciated in Sweden. 

Assuming that the abdominal symptoms associated with the typhoid intes- 
tinal lesions, denote only a variety of one form of fever, Prof. Huss accounts 
for their existence from the fact that the eruption is generally much less 
copious than when these symptoms and lesions are wanting. To quote his 
words : " It is true that these ulcerations (intestinal) occur less spread and 
less in copiousness in the petechial than in the abdominal form, which seems 
to me to be occasioned by the existing antagonism between the skin and the 
intestinal mucous membrane, so that the more copious the eruption is on the shin 
the less are the intestinal glands affected and the contrary." 1 The opinion ex- 
pressed in this quotation is not new. It was advanced several years ago in 
an able article in the British and Foreign Review (vol. xii.), and was adopted 
by Prof. Watson. Its correctness is abundantly disproved by the occasional 
occurrence, on the one hand, of cases in which the typhoid eruption has been 
copious, and the intestinal lesions are found to be marked; and, on the other 
hand, the occurrence of cases in which the typhus eruption is not abundant, 
and, nevertheless, the intestines are unaffected. These facts are alike applica- 
ble to the appearances after death and the abdominal symptoms during life. 

In arguing for the identity of typhus and typhoid fever, Prof. Huss lays 
much stress on the point, that the differences on which is based the doctrine 
of their non-identity are not greater than are presented in different cases of 
other affections which confessedly retain their individuality. He instances 
scarlet fever as a disease offering a wider range of variations than belongs to 
cases, collectively, of typhus and typhoid fever. In a certain sense this state- 
ment is true, but, as an argument, it involves a fallacy which, on a superficial 
examination, may not be obvious. We have already, in the course of these 
remarks, had occasion to inquire into the circumstances which give to any 
disease its individuality, and we have seen that they consist of peculiarities 
from which are deduced laws of the disease distinct from those belonging 
to other diseases, which govern its external characters, its causation, its anato- 
mical changes, etc. These laws of the phenomena, over which they preside, 
compose the natural history of a disease. Now, different cases of the same 
disease may present very great differences without material deviation from its 
fixed laws. These differences may be due to the greater or less intensity of 
certain symptoms. Here the variation is simply one of degree, not of kind, 
but it may give rise to a marked contrast, especially as respects the severity 
or danger of the disease in individual cases. Others arise from accidental 
complications ; for example, pneumonia developed in the course of continued 
fever introduces a train of superadded symptomatic phenomena, yet the laws 
which invest the primary affection with its individuality remains. Scarlatina 
•affords a remarkable instance of exceedingly great diversities arising from 
variations in intensity and complications. Its identity is not lost, because 
these variations do not abrogate the laws regulating its causation, distinctive 
characters, etc. Typhus and typhoid fever have many features in common. 
They have long been confounded in consequence of these points of similarity; 
Yet if the facts referred to in this article are admitted, these laws must be so 
distinctive that the individuality of each cannot be denied. Applying the argu- 
ment of Prof. Huss to prove the identity of scarlet fever and measles, it 
would assuredly be stronger than in its application to typhus and typhoid 
fever. 



1 The italics are the author's. 



156 



Reviews. 



[July 



We have now passed in review the several grounds adduced by Prof. Huss, 
for his belief in the identity of typhus and typhoid fever. In so doing we 
have presented several of the leading points in the argument for the non- 
identity of these affections. We have seen that, contrary to the assertions of 
the author, facts, so far as they have as yet been collected, go to show the 
existence of distinct special causes, causes which separately will produce but 
one and the same disease, never giving rise to the other; that the distinctive 
phenomena of each are preserved with a remarkable uniformity in different 
cases occurring not only at the same time and place, but in successive years, and 
in widely separated quarters of the globe ; that the characters pertaining to 
the eruption serve to distinguish the one from the other, not less than in the 
two eruptive fevers, scarlatina and rubeola* and that certain intestinal lesions, 
which are of a peculiar character, are found nearly, if not quite, constantly in 
fatal cases of typhoid fever, and are invariably wanting in typhus. Contrasted 
in these points of view, the natural history of the two forms of fever involves 
a disparity as respects important pathological laws which is inconsistent with 
their essential identity. 

A full exposition of the argument for the doctrine of non-identity would 
embrace several points which are merely referred to, or overlooked entirely by 
Prof. Huss. Our present limits will admit of only a brief notice of the more 
important of these. 

It is abundantly proved that an attack either of typhus or typhoid fever, as 
the rule secures an exemption from the disease thereafter. Is this true only 
of each disease separately- in other words, will an attack of typhus exempt 
from typhoid fever, and vice versa ? This is an important point in its bearing 
on the question of identity or non-identity. It is to be settled by facts which 
are not easily collected, and at the present moment they have not accumulated 
sufficiently to authorize a positive conclusion. Researches directed to this 
point are desirable. We have reported a single instance in which a patient 
entered hospital with typhoid fever, the characteristic eruption being well 
marked, and was convalescent on the twenty-third day after taking to the bed. 
Twenty-six days after the date of convalescence he was attacked with typhus, 
contracted, probably, from patients in the same ward, the distinctive erup- 
tion being well marked, and convalescence occurred on the seventeenth day. 
He died soon afterwards with tuberculosis of the lungs, and the traces of the 
typhoid intestinal lesions were apparent at the autopsy. 1 

An isolated case, or a few cases only of this description, would not suffice to 
settle the point, for exceptions to the rule, that either form of fever is expe- 
rienced but once, are occasionally met with. An instance of two attacks of 
typhoid fever, the second succeeding the first about a fortnight after conva- 
lescence, has fallen under our observation during the last winter. In both 
attacks the typhoid eruption was well marked. Dr. Jenner has reported an 
instance in which a similar relapse took place. 

Statistics have established a difference of susceptibility to the two diseases 
pertaining to age. Of the persons affected with typhoid fever the vast ma- 
jority are under 40, but persons above this age are not less susceptible to 
typhus. In nearly one-third of the cases of typhus analyzed by Dr. Jenner, 
the patients were 50, or upwards. Prof. Huss gives statistics, as respects 
age, in 3,186 cases of both fevers. He states, that of 27 among these cases 
in which the age exceeded 50, eight had the abdominal form, i. e. typhoid fever. 
These results, while they confirm the rule, show an unusual number of excep- 

1 Clinical Reports on Continued Fever, etc., p. 312. 



1856.] 



Huss, Typhus and Typhoid Fever. 



157 



tions. One cannot avoid the suspicion that, inasmuch as the two diseases 
were believed to be identical they were not discriminated always with accuracy. 
This suspicion is strengthened by recalling the author's assertion that often 
the discrimination is impossible. Moreover, the histories of only 250 cases 
were recorded, and it is not stated that these 27 cases were included among 
the latter. 

The two diseases observe different laws as respects duration. Statistical 
researches show that typhus runs a more rapid career, either to convalescence 
or death, than typhoid fever; that the former stage, or the period from the 
commencement of illness to the time of taking to the bed, is shorter in the 
former than in the latter. Prof. Huss' statistics confirm this distinction. 
They show, also, that in typhus convalescence oftener commences by a crisis 
than in typhoid. He is peculiar in enumerating sleep among the critical 
events, the others being perspiration, epistaxis, and diarrhoea. 

The two diseases prevail together, as a rule, only in certain countries. 
Typhus fever does not occur in France except in certain rare epidemics. It 
is very rarely seen in this country save among foreign immigrants, or when 
it has been derived by contagion from imported cases. It is an indigenous 
fever in Ireland. In this country it is vastly more common among Irish 
immigrants than those coming from G-ermany. The disease, however, appears 
to prevail to a greater or less extent in Germany. It is observed in London 
and Edinburgh ; and from the work of Prof. Huss it appears to exist in Stock- 
holm, but the proportion of cases to those of typhoid fever is small. By an 
approximative calculation, he arrives at the conclusion that out of 3,186 cases, 
892 were cases of typhus, and 2,294 cases of typhoid fever. 1 

It would seem to be a rule that typhoid fever exists wherever typhus is 
liable to prevail, but the former may prevail in localities in which the latter 
is never seen. 

Repeated analysis of cases collected in France, Great Britain, and America, 
have shown that the two diseases do not observe the same laws as respects 
the season of the year when they are most likely to prevail. Typhoid fever 
in the countries just named manifest a decided predilection for the autumnal 
months, while typhus prevails indifferently at any period. On this point, the 
statement of Prof. Huss is remarkable. He says : " The season, also, has, 
in this matter, shown a decided influence ; sporadic typhus occurring during, 
autumn and winter, while spring and summer have introduced the typhoid 
cases." If this statement be correct it shows a variation in the law of typhoid 
fever as respects this point in Sweden. We regret to make use of this quali- 
fication, but the author here, as in other instances relating to the phenomena 
and laws which distinguish the two diseases from each other, merely enun- 
ciates the statement without professing to base it on the results of analytical 
•investigation. Even the 250 cases collected "during the last months of 1843,. 
and the beginning of 1844," are not analyzed with reference to this more than 
to other matters involved in the question of identity or non-identity. In this 
as in other instances, prudence dictates that something more solid and reliable 
than general impressions purporting to be founded on recollected experience 
should be required to invalidate laws confirmed by statistical researches in 
different quarters of the world. 

1 The basis of this calculation is the proportion of instances in which the typhoid 
intestinal lesions were found out of twenty-five fatal cases which occurred within a 
few months. This basis is quite inadequate to furnish correct results, inasmuch as 
in places where both fevers prevail together, great variations are observed in different 
years as respects the predominance of the one or the other. 

No. LXIIL— July 1856. 11 



158 



Reviews. 



[July 



The subject of contagion is hardly touched upon by Prof. Huss. 1 An im- 
portant point of distinction between the two diseases is involved in this subject. 
The contagiousness of typhus is unquestionable, and that typhoid fever may 
be diffused by contagion, we regard as not less conclusively proved. 2 The 
two diseases, therefore, do not present so striking a difference as would exist 
were it true that one is contagious and the other non-contagious. The differ- 
ence, however, is striking in the degree of contagiousness. The communica- 
bility of typhoid fever, under ordinary circumstances, is so rarely exemplified 
that decisive proof of its being ever diffused in this way has, with difficulty, 
been collected. On the other hand, the proof that typhus is transferred from 
one person to another is abundant. In our hospital experience, when cases 
of typhus and typhoid fever were under treatment at the same time and in the 
same ward, we have seen every attendant who nursed these patients contract 
successively typhus, while in not a single instance in hospital cases has typhoid 
fever been communicated. The vastly greater contagiousness of typhus is 
then a highly distinctive feature of this fever. 

Other distinctive circumstances might be cited pertaining both to the symp- 
tomatology and anatomical characters of the two diseases, but a complete dis- 
cussion of the question of their identity or non-identity would lead us beyond 
proper limits. Our object has been to review the grounds taken by the 
author in support of their identity, and in connection therewith to present 
points sufficient, if established, to show a dissimilitude as respects the pheno- 
isnena and laws peculiar to each, that the two must be deemed essentially 
distinct from each other, on the same principle that other diseases are regarded 
.as non-identical ; for example, rubeola and scarlatina. 

One half of the work by Prof. Huss is devoted to the treatment of typhus 
and typhoid fever. The pathological views from which he deduces rational 
principles of management are set forth in the following: — 

" The primitive cause of the typhus process, as far as it is accessible to our 
understanding, seems to be a peculiar change in the blood. The chemical 
characters of this change are: diminished proportion of fibrin and increased 
proportion of several inorganic salts, especially carbonate of soda. This change 
in the blood is carried by the introduction into the system of some foreign 
matter, sometimes a miasm, sometimes a contagion, sometimes a decided poison 
(putrid water, putrid food). It is this foreign matter introduced by means of 
the respiratory or digestive act, that alters the blood in its chemical composi- 
tion and vital power. We apply, consequently, the term zymotic to diseases 
generated in the said way. * * * In one the disease assumes the form 
of typhus petechialis, in another of typhus abdominalis, in still other cases it 
takes an intermediate form between these two extremes. The fever process, 
with all its different phases in whatever form they occur, is a manifestation of 

1 The only reference to this subject which he makes is contained in the following 
quotation: "During both these epidemics a contagion, or noso-comical miasma, 
developed itself within the hospital, which attacked a few patients' who had entered 
the hospital with other complaints, as well as some of the nurses and medical students. 
These got what is called noso-comical fever, but this fever agreed in every respect 
with the prevailing epidemic. Some cases exhibited the petechial form, others the 
abdominal." The same looseness which characterizes other statements is here appa- 
rent. Judging from the facts observed in other hospitals with reference to the differ- 
ence in contagiousness between typhus and typhoid fever, it is probable that analytical 
examination would have shown the disease developed within the hospital to have been 
typhus and not typhoid. 

2 For facts coming under our own observation, on which this conclusion is based, we 
will take the liberty of referring the reader to appendix to "Clinical Reports on Con- 
tinued Fever, etc." 



1856.] 



Huss, Typhus and Typhoid Fever. 



159 



the endeavour of the system to render innocuous, or to throw off the foreign and 
noxious matter received into the body. ,; P. 98. 

The general indications for treatment deduced from the foregoing views are 
embodied in several propositions, as follows : — 

"a. Remove all causes by whose influence the typhus process is generated, 
and all conditions which experience teaches might promote its malignancy. 
Hence, all the hygienic prescriptions, change of abode, strict attention to ven- 
tilation, &c. &c, to which we shall return in another place. 

" b. Counteract the assumed primitive cause of the disease, the altered state 
of the blood, so that it may be kept within the limits necessary to render the 
preservation of life possible. 

" c. Act upon these symptoms from whatever organ they may proceed, which 
are developed with such intensity as to require special attention, and which 
may not be comprised under the preceding indication. 

" d. Promote convalescence, when once commenced, to which it also belongs 
to treat the sequelae, and endeavour as far as possible to prevent their develop- 
ment." P. 100. 

The plan of management which the author adopts is thus eminently expect- 
ant. He has no confidence in abortive measures, nor in our ability by any 
mode of treatment as yet discovered, to shorten the career of the disease. 1 
The cases which prove abortive he explains by "the supposition that the 
power of resistance in the system is strong enough to eliminate the noxious 
matter in some way or other without the aid of a complete pathological 
process. " 

In recommending particular measures or remedies, Prof. Huss does not 
undertake to furnish numerical results. To this, however, we are not dis- 
posed to take exceptions. The eduction of therapeutical principles from 
statistical researches in many diseases is attended with difficulties which render 
this method of investigation but little available ; but its applicability to con- 
tinued fever is especially limited for the following reasons. Statistics show 
that the mortality, both from typhus and typhoid fever, varies greatly at dif- 
ferent times and places when patients are situated under precisely the same 
circumstances, so far as the latter are appreciable, and treated in precisely a 
similar manner. The tendency to a fatal issue is great in some seasons, or 
during particular epidemics, and slight in others, without our being able to 
account for the disparity in this respect. Hence, the rate of mortality is not 
reliable evidence of success or failure as regards the influence of medication on 
the termination of the disease. Duration does not afford a test of the supe- 
riority, or otherwise, of particular methods of treatment, for it is generally 
conceded that we cannot expect to abridge the career of these diseases. So 
far as any inferences may be drawn from mortality or duration, they are nega- 
tive rather than positive. We are warranted in concluding from a small 
number of deaths, and a duration falling below the average, that our thera- 
peutical measures have not exerted an unfavourable influence. There is, 
however, a way in which -numerical investigation may lead to certain positive 
conclusions, viz: enumerating the instances in which the apparent immediate 
effects of remedies denote either benefit or injury. In other words it would 
be practicable, with due care and patience, to determine by means of the ana- 

1 It is an interesting fact that medical science has discovered means of arresting 
fevers which have not a limited career, viz., the periodical fevers, while we are unable 
to cut short or abridge those which end after a certain period from intrinsic limita- 
tions. In the latter class are the eruptive and continued fever, to which maybe added 
yellow fever. 



160 



Reviews. 



[July 



lysis of recorded eases the juvantia et Isedentla with greater precision than 
beloDgs to merely the general impressions based on recollected experience. 
This application of statistical research has been hitherto not sufficiently 
appreciated. 

Of the therapeutical details contained in the portion of the work uuder 
reviewal, we shall enumerate the more important, stopping to notice, briefly, 
certain points which, from their novelty or the emphatic testimony of the 
author, we may presume will be of interest to our readers. 

Emetics, which were formerly much in vogue in the treatment of the early 
stage of continued fevers, have, we believe, in this country, nearly passed out 
of use. Prof. Huss regards them as injurious in most cases, being indicated 
only when the stomach happens to be overloaded at the time when the patient 
is attacked with the disease. He has found no favourable results, in general, 
from the purgative method of treatment. Cathartics are indicated only when 
there is evidence of a considerable congestion of brain, together with more or 
less violent delirium, and under these circumstances only during the first three 
days. The cathartics which he is accustomed to employ are castor oil, calomel, 
and the sulphate of soda. 1 

After a fair trial of general bleeding, he states that his experience entirely 
condemns its use. He has not found it to relieve violent delirium, nor to be 
useful when the disease becomes complicated with pulmonary inflammation. 
Topical bleeding by leeches or cupping, on the other hand, he regards as often 
beneficial when congestion of the brain or spinal marrow is supposed to be 
marked; in capillary bronchial catarrh, and when considerable tension and 
tenderness exist over the ileo-caseal region. Local bleeding, however, as a 
rule, is not judicious after the fifth day, in consequence of the liability to pro- 
duce undue prostration of strength. 

In cases characterized by determination to the head, and active delirium in 
the early stage, he has found the ice-cap frequently highly serviceable. If 
the patient be conscious he is guided in its use and continuance by his sense 
of relief, or otherwise. "When cerebral symptoms are prominent, mustard 
poultices to the thighs, calves, neck, or back, often afford relief. Hot embro- 
cations of turpentine constitute an eligible means of revulsion over the abdomen 
when the abdominal symptoms are prominent, and over the chest when pul- 
monary complications occur. Blisters, as a rule, are to be condemned; they 
are only indicated when grave cerebral symptoms are present, applied, under 
these circumstances, to the back of the neck. 

He attaches considerable importance to the application of compresses wetted 
in cold water over the abdomen in cases of typhoid fever. He says: "I do 
not hesitate to assert that it is one of the most important remedies in treating 
abdominal typhus." Following the application of mustard or hot turpentine, 
he thinks they counteract the tendency to meteorism, lessen the diarrhoea, 
and even render perforation of rarer occurrence than when they are omitted. 
The compresses may be covered with oiled silk to restrain evaporation, or with 
several thicknesses of dry linen, and are to be wetted as often as they become 
dry. They are applied over the chest with advantage when bronchitis or 
pneumonia become developed in the course of the fever. 

1 From a limited trial in cases that have, within the past eighteen months, fallen 
under our observation, we are disposed to thiok favourably of the use of saline laxa- 
tives when the abdominal symptoms, especially tympanites, are prominent. We wit- 
nessed their apparently salutary effects in several instances in Paris during the summer 
of 1854, and we were'informed that they are generally employed, under the circum- 
stances mentioned, in the Parisian hospitals. 



1856.] 



Huss, Typhus and Typhoid Fever. 



1G1 



The administration of the mineral acids, more especially the phosphoric, is 
regarded as a highly important part of the treatment. Of the phosphoric 
acid the author says : — 

" The physicians of France and England [and America may be added] seem 
very seldom to make use of this acid in treating typhus. In Germany, its use is 
often spoken of, and in Sweden it is at present the remedy which the phy- 
sicians most commonly employ. Swedish experience certainly does not weigh 
much in the balance of science. I think, however, that in this matter it merits 
being tried as well by the physicians of France in treating typhus abdominalis, 
as by those of England in the treatment of typhus petechialis.' ; 

Theoretically, he regards the mineral acids as indicated by alterations of 
the blood consisting in diminished fibrin 1 and increased carbonated salts, es- 
pecially soda. The blood undergoes in these fevers changes similar to those 
found to take place in animals which have for a long period taken alkalies, 
and, under these circumstances, it is supposed that acids concur in restoring 
it to a natural state. As the phosphoric acid in the treatment of typhus and 
typhoid fever will be to many of our readers a new remedy, we subjoin the 
author's mode of administration. R. Solut. acidi phosphor. 3ii-iiij decoct, 
althaea, 5iv; syrup, 3 iii. 31. S. A tablespoonful to betaken every other 
hour. 

The solutio acidi phosphorici of the Swedish Pharmacopoeia contains 25 
per cent, of the phosphoric acid. The muriatic and sulphuric acids may also 
be employed, but the author gives a decided preference to the phosphoric. 3 

Turpentine is extolled as a valuable remedy in cases in which bronchial 
catarrh is prominent, and when pneumonia becomes developed. It may be 
administered in emulsion or in capsules. The author remarks, " Before one 
has tried the turpentine under these conditions it would seem d priori that it 
ought to act as an irritant as well on the mucous membrane of the stomach 
and intestines as on the circulating and nervous systems. Experience shows 
us the reverse, or if its action be irritating, this irritation must be beneficial, 
as I never saw it do harm, where the contra-indications stated above" (red- 
ness of the tongue, active delirium and determination to the head) " had been 
observed, but in a considerable number of cases it has acted advantageously 
in the most marked manner." Our readers need not be reminded of the fact 
that in this country turpentine is by many considered as a highly useful 
remedy with express reference to the typhoid intestinal affection. For this 
object it is strongly recommended by Prof. Wood. 

Active delirium, which the author attributes (but incorrectly as we sup- 
pose) to congestion of the brain, is treated by ice to the head, cupping on the 
neck, mustard poultices to the extremities, and the tartrate of antimony. 
The remedy last named, more particularly since the strong testimony by Dr. 
Graves, of Dublin, to its efficiency, in combination with opium, in relieving 
the delirium of fever, has been much employed by physicians for that end. 
We can testify from our own experience to its usefulness. We have found 
the remedy efficacious in less doses than those advised by Dr. Graves. In 
this respect, our practice coincides with that of the author, who gives from 
i to i grain in aqueous solution every other hour. The author cautions 
against its being too long continued, advising to withhold it after two or three 

1 According to Lehmann, diminution of the fibrin of the blood does not constantly 
obtain in essential fevers. — Physiological Chemistry, vol. i. p. 320, Am. edition. 

2 A medical friend of ours, a practitioner of considerable experience, relies mainly 
on the administration of alkalies in the treatment of typhoid fever, and claims that 
the excellence of this method is proved by its success. 



162 



Reviews. 



[July 



days. Generally we have found it sufficient to administer it during the even- 
ing or night when the delirium is most apt to be manifested, or when, if con- 
stantly present, it is increased. 

During the latter part of the disease, or, as the author terms it, the sta- 
dium depressionis, excitant remedies are often required. He attaches great 
importance to the sounds of the heart as furnishing an index of the state of 
the muscular system and vital forces. ' We quote his remarks on this point. 

" To study the sounds of the heart, and especially the first sound, I consider 
to be very important and very useful in determining the use as well of cam- 
phor as of the other excitant remedies. The state of this sound is certainly 
closely connected with that of the pulse, but I think the ear a more accurate 
observer of the strength of the heart than the finger of that of the pulse. * ¥ * 
The weakness of the muscular system in general being a sign of the general 
depressio virum, the weakness of the action of the heart, measured by the 
change of its sounds, is an accurate, nay the most accurate measure of the 
general depression, and indicates most exactly the use of excitantia. In cases 
where the sounds do not undergo any alteration, these are neither indicated 
nor necessary. " P. 147. 

The importance of auscultation of the heart, as our readers are aware, has 
been emphatically inculcated by Dr. Stokes, with whose writings American 
physicians are familiar, but we suspect that it is less resorted to in practice 
than its importance claims. 

Among the remedies of the excitant class which may be usefully adminis- 
tered, when the indications are present, the author notices camphor, the 
carbonate of ammonia, musk, and phosphorus. 

Of diffusible or alcoholic stimulants wine only is mentioned, and this is 
very sparingly given. He says: "I allow only so much to be mixed with 
the driok as to give to it a slight taste, the whole quantity allowed in a day 
being one or two wineglasses. Port and sherry are the kinds I have used; 
its effect must, however, be closely watched, and if the wine excite too much, 
it must no longer be given." 

Were it consistent with our plan to enter into discussions concerning thera- 
peutical principles and remedies, we should take issue with the author on the 
use of stimulants. So far from the great circumspection in their use which he 
enjoins being necessary, we are satisfied that, when sustaining measures are 
indicated, they may be administered more or less freely, according to the indi- 
cations, so as to render the excitant remedies just referred to of subordinate 
importance, and even comparatively useless. We say this on the strength of 
considerable experience. As a rule, we think spirits are to be preferred to 
wine. The circumstances which denote the propriety of stimulants, and the 
extent to which their use is to be carried, are, of course, in a practical point 
of view, of great importance; but to consider them here would be a digression 
from our present object, which is simply to give a summary of the more im- 
portant points pertaining to treatment which are contained in the work under 
reviewal. 

Under the head of tonics, the author mentions only quinia. This holds, in 
his estimation, a low rank among the remedies indicated in typhus and typhoid 
fever. He has no confidence in the power which has been claimed for it of 
cutting short a continued fever as it does an intermittent or remittent. When 
this result follows, either the disease would have aborted without the remedy, 
or there has been an error of diagnosis. Continued through the whole career 
of the disease, as is the custom with some practitioners, he thinks it may act 
injuriously, especially in the second stage. The conditions under which ifc 
may be given with advantage are contained in the following extract : — 



1856.] 



Huss, Typhus and Typhoid Fever. 



163 



" "When the excitantia have been given, and the symptoms against which 
these were prescribed are subdued, but the fever nevertheless continues, and 
the strength is very low, without any sign of approaching improvement ; the 
pulse continues frequent and irritable, the skin either dry and rough, or covered 
with clammy perspiration, the spleen more or less swollen, but the tongue clean 
and moist, the quinine is in its place. Also, when, in consequence of the in- 
testinal ulcerations, or suppurating ulcerations elsewhere, a state resembling 
pyeemia is developed, as well as in the cases where there exist marked remis- 
sions in the fever, which is not seldom seen in typhus cases occurring during a 
prevalent epidemic of intermittent." P. 155. 

The following quotation contains all that is said under the head of dietetic 
rules : — 

" The dietetic direction during the first stage being in conformity with the 
patient's own feelings, is limited to abstinence from food ; the same proceeding 
is not quite so applicable during the second. My experience has shown that the 
patient then feels well from taking some food, although it must be of the sim- 
plest and mildest kind. For drink I allow warm milk from the beginning of 
this stage, mixed with carbonated water in equal parts, or soups of oats, sago, 
rice, also mixed with this water, and some wine, according to circumstances. 
Later in this stage, small quantities of chicken or veal broth are given — a table- 
spoonful several times a day. We must, however, carefully watch its effects, as 
should the broth seem to excite too much, its use must be suspended. Jellies, 
animal and vegetable, too expensive to be employed at hospitals, are in private 
practice very useful during this stage, if given in small quantities, and often 
repeated." P. 177. 

The author evidently does not appreciate the importance attached, of late 
years, by some British and American writers (amongst whom the late Dr. 
Graves is especially to be mentioned), to alimentation in the treatment of 
fevers. For many years we have been satisfied that the administration of 
concentrated nutriment, in conjunction with stimulants, constitutes a branch 
of the management which, in general, ranks above all other measures. With 
the added experience of each year, we are the more convinced of the advan- 
tage of (to use Dr. Graves' expression) " feeding fevers." The practice of 
Prof. Huss in this respect is well as far as it goes, but it does not go far 
enough; and he interposes restraining cautions, which, in our opinion, are 
gratuitous. Alimentary analeptics are admissible earlier than he advises, and 
are useful by way of forestalling prostration. It is better to run the risk of 
entering on sustaining measures too soon than of deferring them too long, for 
it is easy to suspend their use if they are found to do harm, while lost time 
cannot be regained. So when they are indicated by existing prostration, the 
injury from an inadequate supply of stimulants and nutriment is vastly 
greater than from excess, provided the effect is watched, and the quantities 
thereby graduated. 

The author devotes a distinct section to the treatment of special symptoms. 
We do not, however, find under this head aught which, from its novelty, 
interest, or importance, claims particular notice. The same remark is appli- 
cable to the management of convalescence, and of the sequelae. 

Although, in commencing to write this article, we did not intend to be 
hampered by a constant regard for brevity, we have occupied somewhat more 
space than we had contemplated; but we trust not more than, in the judg- 
ment of the reader, is due to the scientific interest and practical importance 
of the subjects, especially that to which the larger portion of our remarks 
has been devoted, viz., the non-identity of typhus and typhoid fever. In 
taking leave of the work by Prof. Huss, we must confess that it has disap- 



164: Revieics. [July 

pointed our expectations, not because tbe author contends for the unity of 
continued fever, but in consequence of the manner in which he has treated 
this subject. Purporting to be a work devoted to statistics of typhus and 
typhoid fever, embodying the experience of several years at a large hospital, 
we had hoped to find the question of the identity or non-identity of these 
affections tested anew by a comparison of the results of the numerical analysis 
of a series of cases of each fever separately j and we were anxious to see 
whether the results of observations made in the capital of Sweden would cor- 
respond or differ from those obtained in France, England, and America. 
Instead of this, the work, so far as this question is concerned, only gives the 
opinions of the author, backed by whatever authority may be derived from 
the fact that he has seen and treated a large number of cases of both forms of 
fever. The force which belongs to such opinions different persons will un- 
doubtedly estimate differently. We do not, however, hesitate to attach to 
them small importance when brought into antagonism with conclusions 
reached by the analytical investigation of recorded cases. The statistics 
relating to both typhus and typhoid fever indiscriminately possess a certain 
value, provided these affections are identical ; otherwise they are comparatively 
valueless. 

With the portion of the work devoted to treatment, we are less dissatisfied. 
Although there is here room for criticism, the therapeutical views which the 
author advances, and the pathological notions on which they are founded, are, 
we believe, in the main, in accordance with the opinions and practice of the 
most intelligent and judicious practitioners of the present time. 

A. F. 



Art. XII. — Chimie Appliquee a la Physiologic et a la Tlierajpeutique. Par 
M. le Docteur Mialhe, Pharmacien de l'Etnpereur, Professeur Agrege a 
la Faculte de Medecine, &c. &c. Paris, 1856. 

M. Mialhe's book is a reproduction, in great measure, of separate essays 
published by him at various intervals between 1840 and 1850; and it is 
remarkable to see how many of his physiological doctrines, whether adopted 
or original, which have been either modified or entirely superseded by the 
advance of the science since the date of their first appearance, are retained by 
the author, and re-stated with as much confidence as ever. After passing 
through, in the introductory pages, with some general considerations on the 
character of the chemical changes taking place in the healthy body, and the 
proper mode in which they are to be studied, he takes up, in the first chap- 
ter, the consideration of the phenomena of oxidation and nutrition — com- 
mencing with those of oxidation. He makes a division of all the alimentary 
substances according to Liebig's celebrated hypothesis, into plastic and re- 
spiratory elements. Of these, the former are mostly used in the nutrition of 
the tissues, and the latter — such as sugars and oils — almost completely de- 
stroyed by direct oxidation in the blood; terminating, therefore, soon after 
their ingestion, in the production of water and carbonic acid. The very im- 
portant objections to this doctrine, which have recently been acknowledged 
by the leading physiologists, seem to have nearly or quite escaped the author's 
notice. He speaks constantly of those substances which, on being taken into 
the system, do not reappear in the excretions, as necessarily " burnt" in the 



1856.] Mialhe, Chemistry applied to Physiology and Therapeutics. 165 



circulation; and regards the natural heat of the body as the result of the 
same corabustive process. These are all opinions which were adopted some 
time since, and are now modified or abandoned in consequence of their resting 
too evidently on insufficient data; several very important links in the proof 
being entirely wanting, or supplied only by inference. There is one theory, 
however, advanced by M. Mialhe, in this connection, which is, we think, a 
novelty, and at the same time a striking instance of the common, but very 
dangerous practice of inferring a chemical reaction to take place in the body 
without any direct proof, and simply because its materials exist there. It is 
in regard to the mode of action of various poisonous substances, and particu- 
larly of hydrocyanic acid. The author, after speaking of the constancy and 
rapidity with which the " intravascular oxidation" goes on in the body, and 
its importance to the continuance of life, goes on to remark, that any sub- 
stance which should interfere with this oxidation, would, by that fact alone, 
become poisonous. Some substances actually do, as he thinks, have such an 
effect. Chloroform and sulphuric ether, for example, introduced into the 
blood, are thought to displace its oxygen in this manner, and to suspend life, 
during the continuance of their anaesthetic effect, by simply arresting the pro- 
cess of combustion. The volatile oils are considered as liable to exert the 
same influence by reason of their avidity for oxygen ; and sulphuretted, sele- 
niuretted, and arseniuretted hydrogen also act by depriving the blood of its 
oxygen, while they are at the same time converted into other compounds, 
poisonous by themselves. 

" We can very easily understand, then," says M. Mialhe (p. 29), "how rapidly 
fatal would be the operation of any substance which should have the power of 
seizing at once upon all the oxygen contained in the blood, and destined for 
the supply of respiration and nutrition. Such would be the action of phospho- 
rus, provided it were possible to administer this body in a gaseous condition. 
The same effect would be produced by any substance endowed with the pro- 
perty, without itself becoming oxidized, of suddenly putting an end to the 
process of intravascular combustion. Such a poison would act on the living 
body like a stroke of lightning. Now we know there is a poisonous substance, 
whose operation is in reality like that of a stroke of lightning, viz : hydrocyanic 
acid. It results from the researches of M. Millon that this acid has a remark- 
able tendency to interfere with certain phenomena of oxidation, or combus- 
tion; and that, even in very small quantity, it prevents entirely the powerful 
combustive action of iodic acid upon oxalic acid. Considering the relation 
which exists between the two phenomena of respiration and oxidation, we may 
conclude that the only effect of hydrocyanic acid, introduced into the organism, 
is to cut short the process of vital oxidation, and produce in that way an in- 
stantaneous death." 

It would be difficult to imagine a physiological theory more destitute of 
direct evidence than this ; or one which depended for its support upon re- 
moter analogies. 

In his chapter on the digestion of starchy substances, M. Mialhe reproduces 
almost entirely the opinions which he professed ten years ago with regard to 
the importance of " animal diastase," or the organic substance of the saliva, 
and its identity with vegetable diastase, as well as with the organic matter of 
the pancreatic juice. He was among the first to extract this substance from 
the saliva, and to recognize its power of transforming starch into sugar. He 
still continues to attribute to it a very important part in the chemical pro- 
cesses of digestion, though this opinion is now, and has been for some years, 
generally abandoned, for experimental reasons which do not seem to be re- 
garded by the author as having the importance which is usually attributed 
to them, 



166 



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[July 



The question of the origin of svgar in the animal economy is disposed of 
in a still more loose and unsatisfactory manner. M. Mialhe contents himself 
with stating, in very concise terms, the important doctrine maintained by 
Bernard, that a certain quantity of sugar is constantly produced in the liver 
from metamorphosis of the elements of the organ itself ; and then proceeds 
to express his dissent from it in the following brief terms : — 

"For our part, we cannot share the opinions of M. Bernard. For us, the 
liver is not a secreting organ for the sugar, but only an apparatus of conden- 
sation, in which the sugar accumulates, after being taken with the food ; in the 
same manner as the liver also condenses in its tissue certain metallic poisons 
introduced into the economy." (P. 61.) 

The many experiments performed and reported by Bernard, in opposition 
to this very objection, and the long contest carried on, during the past year, 
before the French Academy on the whole question, in which Longet, Figuier, 
Bernard, and Lehmann all took a part, and during which a special committee 
investigated the matter and reported favourably to Bernard, are all passed 
over in silence; though they ought certainly to have some weight in deciding 
so very interesting a physiological question. 

In his concluding paragraph of this section the author also misrepresents 
Bernard's doctrine in a very singular manner : — 

" If the sugar be not derived," he says (p. 61), " exclusively from amylaceous 
elements of the food (since it is now demonstrated that muscular flesh and the 
white of egg contain a certain quantity of it), it is nevertheless an undeniable 
Tact, admitted by M. Bernard himself, that the quantity of sugar existing in 
the organism is in direct proportion to the quantity of starchy matters absorbed 
from the digestive apparatus. So the liver, whether it be a secreting or sim- 
ply a condensing organ, derives after all from the food the saccharine elements 
which it supplies to the circulation." 

This is certainly unjust, both to Bernard and his doctrine; for one of the 
points upon which he most positively insists is, that the liver is not dependent 
for its saccharine supply upon starchy matters in the food; that as much 
sugar is produced by it under an animal as a vegetable diet ; that even after 
several months' strict regimen on food carefully deprived of amylaceous mat- 
ters, it is still as abundant as when the food was of a mixed character ; and 
that, finally, the sugar of the liver, instead of being derived from any starchy 
elements, is produced in the tissue of the organ itself, by a transformation of 
its own substance. (Bernard, Nouvelle Function du Foie, Paris, 1853.) 

In treating of the destruction of sugar in the animal economy, M. Mialhe 
describes first the usual reactions of a saccharine substance when treated, in 
solution, with acids, alkalies, and metallic salts, and particularly its power of 
reducing the salts of copper, when heated in an alkaline solution. Sugar 
alone, he observes, will not produce any reduction of the oxide of copper ; 
but in order to produce this effect it must be accompanied with an alkali or 
alkaline carbonate. The body which becomes oxidized, therefore, at the ex- 
pense of the copper, is not the sugar itself, but the new substances (ulmic, 
formic, and glycic acids) into which it has been previously converted by con- 
tact with the alkali. He regards the phenomenon of the reduction of metallic 
compounds which sometimes takes place in the body (as in the case of the 
salts of copper, red ferrocyanide of potassium, &c.) as owing to the presence 
of the formic and ulmic acids, &c. into which the sugar has been converted 
by the alkaline carbonates of the blood. It is in this way that he arrives at 
the following theory of the natural transformation of the sugars in the circu- 
lation : — 



1856.] Mialhe, Chemistry applied to Physiology and Therapeutics. 167 



" On its arrival in the blood the glucose decomposes the alkaline carbonates, 
forming with their bases new compounds, glycosates, and setting free their 
carbonic acid ; the glycosates, which are unstable compounds, are rapidly 
transformed into glycic, ulmic, and formic acids, or rather into glyciates, 
ulmiates, formiates, which combine with the oxygen of the blood, and undergo 
a veritable combustion, with the production of water and carbonic acid." 
(P. 67.) 

The above theory of the destruction of sugar in the blood will be found, 
on examination, to rest on four successive propositions, each essential to its 
establishment, and all of them more or less hypothetical : — 

1. In the reduction of copper from an alkaline saccharine solution, tho 
alkali acts by first converting the sugar into ulmic, glycic, and formic acids. 

2. When metallic salts, and particularly those of copper, are reduced in 
the animal economy to a lower state of oxidation, the agents of this reduction 
are the ulmic, glycic, and formic acids. 

3. These acids are produced from the sugar of the blood by the action of 
the alkaline carbonates. 

4. And finally, the water and carbonic acid, expelled from the system, are 
(partly) formed by direct oxidation of the above acids. 

None of the above propositions are free from doubt. With, regard to the 
first, though the presence of an alkali be certainly necessary to the operation 
of Trommer's test for glucose, we are not aware that its precise mode of 
action, as above described, rests on anything more than inferential grounds. 

In the second place, the reduction of metallic salts, when it occurs in the 
animal economy, may certainly be owing to the action of other bodies beside 
formic acid, &c. The albuminoid substances themselves absorb oxygen with 
great readiness under every ordinary condition, and may even produce, by 
their presence, a partial reduction in the solution of copper, used as Trom- 
mer's test. Thirdly, formic acid has undoubtedly been found in the blood 
and various other fluids of the body ; but its source is unknown. Even in 
the red ants, from which it was formerly obtained in the greatest abundance, 
it is yet quite uncertain whether it be produced in the body of the insect, or 
introduced with the food from some vegetable source. And, lastly, the direct 
oxidation of these acids, when present in the body, is itself a matter of doubt. 
Indeed, formic acid has been found (by Lehmann) in comparatively large 
quantity in the normal perspiration. If it were, therefore, so readily oxidiz- 
able in the system as to reduce the salts of copper, when these are present, 
it is not easy to understand how it should itself escape destruction by the 
free oxygen of the blood, and arrive unaltered at the surface of the skin. 

The theory of the mode of disappearance of the animal sugars, adopted by 
M. Mialhe, conducts him very readily to an explanation of the morbid phe- 
nomena of diabetes. In health, the normal sugars of the blood are destroyed 
by the influence of its alkaline carbonates. Anything which diminishes the 
alkalescence of the blood will therefore tend to produce an accumulation of 
sugar in the system, and a consequent diabetic condition of the blood and all 
the secreted fluids. M. Mialhe does not hesitate, therefore, to attribute the 
condition of diabetes to a preponderance of acids in the system by which the 
alkalescence of the blood is neutralized, and the oxidation of the sugar pre- 
vented. This preponderance may be occasioned, he says, by an abuse of 
acidulated drinks, by an exclusively azotized diet, or by a suppression of the 
cutaneous transpiration. Animal food, containing principally compounds of 
sulphur and phosphorus, gives rise in the body, by oxidation, to sulphuric 
and phosphoric acids; while vegetable food contains salts of the organic 



168 



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[July 



acids (citrates, rnalates, &c), which are destroyed by oxidation, leaving a 
residue of alkaline carbonates. A proper admixture of the two is thought to 
maintain the natural alkalescence of the blood, while a too great proportion 
of animal food diminishes or entirely neutralizes it. Finally, the cutaneous 
transpiration is one channel through which the free acids are eliminated from 
the system. There are, says M. Mialhe, five secretions with an alkaline 
reaction, viz., the tears, saliva, bile, and pancreatic and intestinal juices : and 
three which are acid, viz., the sweat, gastric juice, and urine, by whose con- 
stant activity the natural balance between acids and alkalies is preserved. If, 
however, the cutaneous transpiration be checked, its acid ingredients are re- 
tained in the system, the fluids lose their alkalescence, the sugar is not 
destroyed, and diabetes is the consequence. M. Mialhe therefore main- 
tains," in a formal manner, " that the cause of diabetes is the want of assi- 
milation of glucose, through an insufficiency of the alkaline principles in the 
economy. " (p. 77.) 

We should anticipate at least, then, from so confident a statement, that 
this want of alkalinity in the blood, in cases of diabetes, had actually been 
observed ; and that this fact served as a basis for the author's opinion. Far 
from it. M. Mialhe even acknowledges, with an admirable candor, the 
difficulty of the objection that, in point of fact, the blood of diabetic patients 
"is never acid or neutral; but always maintains an alkaline reaction •" and 
the singular manner in which so apparently stubborn a fact is disposed of, is 
not the least remarkable part of his theory. In the first place, he says it is 
" exceedingly difficult" to determine by experiment the precise degree of 
alkalinity of the blood; intimating, therefore, that it may be diminished in 
diabetes, without our having observed it. But the remaining part of his 
answer to the above objection is the more important, and its ingenuity de- 
serves a quotation in the author's own words: — 

"In the condition of health," he says (p. 76), "the alkalinity of the blood is 
determined mainly by the alkaline carbonates, but to a slight degree, also, by 
the alkaline phosphates ; these last, notwithstanding their power of restoring 
the blue colour of reddened litmus, are not included by chemists in the list of 
alkaline substances proper ; and, furthermore, they do not. as we have proved, 
give rise to the decomposition of glucose. Now it is our belief, that in diabetic 
patients the blood remains alkaline because it is rich in phosphates and poor in 
carbonates, so that the degree of alkalinity, produced by the presence of the 
phosphates, is entirely inefficient for the decomposition of the glucose; which 
can only be effected by the influence of the carbonates. " 

It is upon such grounds that M. Mialhe rests his theory of the pathology 
of diabetes. 

The remainder of the first portion of the book is occupied with the con- 
sideration of the digestion of albuminoid and fatty matters, the endosmotic 
properties of albumen and albuminose, and the occasional passage of these 
substances into the excretions and exudations. It contains little that has not 
been already before the profession, or that is presented in such a way as to 
excite any great degree of interest. 

The remaining chapters constitute by far the most interesting and important- 
portions of the book. They are devoted to the absorption and chemical trans- 
formation in the system of drugs and poisons. But very little has yet been 
done in this field. Almost all we know with regard to the subject is. that 
such and such matters are, or are not, absorbed into the blood; or that fcney 
do, or do not, make their appearance in the secretions. The manner of their 
absorption, and the changes which they undergo before elimination, constitute 



1356.] Mialhe, Chemistry applied to Physiology and Therapeutics. 169 



an extremely important subject, the study of which may be said to be now 
first commenced in earnest by M. Mialhe. He commences by establishing 
the principles that no substance can have any action on the living body with- 
out being absorbed; and no substance can be absorbed without being liquefied 
and soluble ; and then passes in review the actions of iodine, sulphur, phos- 
phorus, metals and metallic salts, resins, volatile and fixed oils, and the vege- 
table alkaloids with their salts. 

Notwithstanding the very slight solubility of iodine in water, when ad- 
ministered internally, or applied to a denuded surface, it rapidly undergoes 
changes which result in its absorption. A minute portion of it, according to 
M. Mialhe, is dissolved by the water of the fluids, and is then converted into 
iodides and iodates by the action of the alkaline carbonates ; and, as the iodides 
of potassium and sodium themselves exert a powerful solvent action on free 
iodine, a large portion of this at once enters into solution, and, as the author 
believes, coagulates the animal matters of the fluids; the coagulum afterwards 
disappearing by the gradual conversion of the iodine into iodides and iodates 
by the alkaline chlorides and carbonates of the blood and their subsequent 
absorption. He lays it down, therefore, as a precept, that iodine should never 
be administered in substance or in alcoholic tincture, in any case where it is 
our object to produce merely a constitutional effect; since its coagulating 
tendency is productive of a troublesome local irritation, and interferes, at the 
same time, with the absorption of the drug. A much better form, under 
almost all circumstances, is the iodide of potassium, which is already soluble, 
and does not coagulate or irritate the tissues. Iodide of potassium, as it is 
usually administered, does, it is true, sometimes produce a considerable degree 
of gastric irritation ; but this is owing, according to Bff. Mialhe, to the pre- 
sence of iodate of potass, which not unfrequently, as he says, occurs as an 
accidental impurity in the iodide of potassium of the shops. This iodate of 
potass is decomposed by the acid of the gastric juice and its iodine, liberated 
from union with the potass, acts on the mucous membrane as a coagulating 
and irritating substance. 

Sufyhur is thought to be capable of absorption when administered internally, 
notwithstanding its insolubility in water. The fact seems to be sufficiently 
proved by its frequently producing a general constitutional excitement in addi- 
tion to its laxative effect, by the sulphurous odour it communicates to the 
breath and excretions, and finally by the property which it communicates to 
the skin, after prolonged administration, of blackening certain metallic sub- 
stances. This absorption is accomplished by the alkaline carbonates of the 
intestinal fluids, which transform the sulphur into alkaline sulphurets and 
hyposulphites, substances which are soluble, and, consequently, directly ab- 
sorbed into the circulation. Arrived at the skin, these combinations are 
decomposed by the acid of the perspiration, and hydrosulphuric acid is disen- 
gaged if the excreted substance be a sulphuret, and sulphurous acid with free 
sulphur if it be a hyposulphite. "Whether sulphur be administered by the 
stomach or by the endermic method, therefore, the author recommends that 
it be always associated with an alkali (potass, carbonate of magnesia, or soda), 
in sufficient quantity to neutralize the acid reaction of the gastric or cutaneous 
fluids, and in addition to form soluble sulphurets and hyposulphites with the 
drug. 

l J hosp)horus, equally insoluble in water with sulphur, is thought to be ab- 
sorbed by a very similar process, being converted by the alkaline intestinal 
juices into phosphoretted hydrogen and hypophosphites of soda and potass. 
It should therefore be given dissolved in oil or ether, in order that it may be 



170 



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[July 



thoroughly exposed to the contact of the intestinal fluids, and its transforma- 
tion into soluble substances effectually secured. 

Arsenic, in a metallic state, is regarded as entirely insoluble, incapable of 
absorption, and without action on the living tissues; but nevertheless as prac- 
tically a very poisonous substance, because it readily becomes oxidized and 
converted into arsenious acid. M. Mialhe has convinced himself not only 
that metallic arsenic readily gives rise to arsenious acid when exposed to the 
contact of moist air, or water containing air in solution, but also that this 
oxidation is much facilitated by the presence of the chlorides of potassium or 
sodium; and as the greater part of the animal fluids contain both oxygen 
and the alkaline chlorides, powdered metallic arsenic must, when introduced 
into the body, always give rise to more or less arsenious acid, and become 
absorbed under that form. 

In the treatment of arsenical poisoning, the antidote which has heretofore 
been regarded with most favour is the hydrated peroxide of iron. M. 
Mialhe proposes, as much more efficacious, the hydrated sulphuret of iron, 
which produces by decomposition an insoluble sulphuret of arsenic and a per- 
oxide of iron. He says that a comparative experiment with these two sub- 
stances and a solution of arsenious acid shows that the hydrated sulphuret of 
iron decomposes the poisonous substance much more rapidly than the hydrated 
oxide. The insoluble sulphuret of arsenic is, however, slowly reconvertible 
into arsenious acid by the chlorides of the intestinal juices; and the antidote 
should therefore be always administered in excess, in order to guard against 
such an accident. The great advantage, however, of the hydrated sulphuret 
of iron, and for which M. Mialhe particularly recommends it, is, that it is 
an antidote, not only for arsenic, but also for all the metallic salts Halle to be 
used as poisons, except cyanide of mercury — reducing, in the same manner 
with arsenic, the salts of copper, lead, tin, antimony, bismuth, mercury, and 
silver ; so that in any case of doubt as to the precise nature of the metallic 
poison which had been administered, it would be infinitely safer as an antidote 
than the hydrated peroxide. 

In treating of the mode of action of the different preparations of iron, the 
author considers it as certain that nearly all of them are efficacious, to a cer- 
tain extent, as remedies, and more particularly in the regeneration of the 
blood-globules in chlorotic patients. Those preparations which are insoluble 
in water, are mostly soluble in the acids of the gastric juice, and act afterward 
in the same manner as the soluble compounds. The mode in which he ima- 
gines the metallic preparation, however, to produce its final result, is a little 
complicated. He finds, in the first place, that all the soluble salts of iron, 
without exception, precipitate with the animal matters of the gastric juice. 
The insoluble preparations, including metallic iron, are first dissolved by the 
acid of the gastric fluids, and then precipitate at once, like the former, so 
soon as these fluids are in excess. A small portion of the iron, however, 
escapes precipitation, is taken up by the blood, and meets there with the alka- 
line carbonates, by which it is decomposed ; the insoluble oxide of iron which 
is set free being appropriated by the blood-globules, and prevented by its in- 
solubility from escaping by the secretions. It is in this way, according to 
the author, that it contributes to the regeneration of the blood-globules and 
the cure of chlorosis. 

According to this theory, the only preparations of iron useful in the treat- 
ment of chlorosis, are those whose compounds, dissolved in the gastric juice, 
and absorbed into the blood, are decomposable by the alkalies, leaving an 
insoluble oxide to be retained in the system — such as metallic iron and its 



1856.] Mialhe, Chemistry applied to Physiology and Therapeutics. 171 



oxides, chlorides, bromides, iodides, and, without exception, all its oxysalts. 
On the other hand, those preparations, such as ferrocyanide of potassium, 
not decomposable by the alkalies of the blood, remain soluble, pass into the 
secretions, and merely traverse the body without producing any therapeutical 
effect. The preparation which the author regards as the most efficacious is 
the double tartrate of iron and potass, which he prefers for the following rea- 
son : All the other oxysalts, as has just been mentioned, after allowing a 
minute quantity to be absorbed from the stomach, precipitate with an excess 
of gastric juice, and pass into the intestine. Here they are decomposed by 
the alkaline fluids of the intestine, and the whole remaining iron set free in 
the form of an oxide, which passes through the intestine unaltered, and is 
discharged with the fasces. The only one of these preparations not decom- 
posable by the alkalies is the tartrate of iron and potass. It therefore con- 
tinues to be absorbed through the entire length of the intestine, and intro- 
duces into the blood a much larger quantity of iron, for the same dose, than 
can be the case with any of the other preparations. Once introduced into 
the blood, however, its tartaric acid is destroyed by oxidation, replaced by 
carbonic acid, and the carbonate of iron is then decomposed by the alkalies, 
and its oxide retained in the system, as already described. 

How much of the above is the result of direct experiment, and how much 
inferential, it is not always easy to determine from the author's account. He 
starts, however, with some very grave errors, which detract considerably from 
the value of his conclusions. He regards, for instance, the two following 
facts as " incontestablement acquis a la science." 

1. " The globules of the blood contain a combination of iron; no other 
part of the living body contains iron." (P. 285.) 

It should hardly have escaped the recollection of the author that, at the 
present day, iron has been demonstrated to exist, in the healthy condition, 
in the urine, the sweat, saliva, gastric juice, and bile, as well as in the blood- 
globules. 

2. " The combination of iron contained in the globules presents the re- 
actions of an oxygenated compound of the metal;" from which the conclusion 
is drawn that the iron is combined with the globules under the form of an 
oxide. 

The grounds, however, upon which this opinion was first adopted, have 
been found to be quite insufficient ; and it is now acknowledged by the first 
authorities in organic chemistry, that we are entirely ignorant as to the par- 
ticular combination under which iron exists in the blood-globules. (Lehmann, 
Robin and Verdeil.) 

Although these errors, however, may invalidate the author's theory with 
regard to the ultimate mode of action of the compounds of iron in the system, 
they do not necessarily impair his conclusions as to their mode of absorption, 
or the superiority which he claims for the tartrate of iron and potass over the 
other ferruginous preparations. 

The researches of the author on the preparations of lead bring him to the 
conclusion that they are all, as well as metallic lead, when introduced into 
the digestive canal, acted on by the alkaline chlorides of the intestinal juices, 
and converted into chloride of lead; this again unites with the excess of 
chlorides remaining, so as to produce a double chloride of lead and potassium 
or sodium. This " alkaline chloro-plombate" is distinguished from the sim- 
ple chloride of lead by being more soluble than it, and not forming any pre- 
cipitate with an albuminous fluid. It is therefore much more readily absorbed, 
and enters freely into the circulation. When, therefore, any soluble and 



172 



Reviews. 



[July 



coagulating saturnine preparation — as, for example/the subacetate of lead — 
is taken into the stomach, its first effect is to precipitate with the albuminous 
matters of the digestive fluids. But it is afterward decomposed by the chlo- 
rides, and absorbed under the form of a double chloride into the circulation. 

A very interesting series of experiments are reported by M. Mialhe, which 
he undertook with the view of ascertaining whether any of the compounds of 
lead could be given off as gaseous exhalations when mixed with spirits of tur- 
pentine. It has been thought that paints, having compounds of lead for 
their basis, when used with volatile oils, might give rise while drying to 
emanations containing lead, and become poisonous by inhalation. M. Mialhe 
has demonstrated, however, by a very ingenious and satisfactory contrivance, 
that this is not the case; and that any injurious effects produced by such 
emanations must be attributed to the spirits of turpentine, since they contain 
no lead that can be chemically demonstrated, even when examined in a very 
concentrated form. 

One of the most important chapters in the book relates to the action of 
the mercurial compounds. According to the author's investigations, all the 
preparations of mercury in use as medicinal agents, are converted, to greater 
or less extent, by the chlorides of the animal juices, into corrosive sublimate; 
and that, whatever be the compound employed, the bichloride is the only 
active agent in the production of its constitutional effects. He finds that 
calomel, exposed to the action of a solution of chloride of sodium and sal am- 
moniac, produces, at the end of twenty-four hours, a quantity of corrosive 
sublimate, which varies according to the amount of alkaline chlorides pre- 
sent, and the elevation of the temperature at which the mixture is kept. 
Similar results were obtained with the other preparations of mercury. The 
addition of various organic matters — sugar, gelatine, albumen, &c. to the mix- 
ture, sometimes retarded, but never entirely prevented the reaction. It even 
took place when calomel was mixed with the serum of the blood; and 
finally, the author has reason to believe that he has detected bichloride of 
mercury in the urine, after calomel had been administered by the stomach. 
The bichloride itself, then, in minute doses, if managed with prudence, might 
replace all the other preparations of mercury. Still, calomel has some prac- 
tical advantages, which will probably enable it always to retain its place as 
a therapeutical agent. Taken into the stomach in an insoluble form, it is 
very slowly and gradually tranformed into the bichloride, and constantly 
absorbed in successive minute doses during its entire passage through the 
intestinal canal. Its local action is, therefore, very mild, and an overdose 
is not liable to be attended with any serious results, since the amount of 
bichloride produced is not in proportion to the calomel ingested, but to the 
quantity of the chlorides which it meets with in the intestine; and these 
never occur in so concentrated a form as to produce dangerous results. The 
different preparations of mercury are, therefore, more or less active in pro- 
portion to the readiness with which they become converted into corrosive 
sublimate under the influence of the alkaline chlorides. M. Mialhe arranges 
them in the order of their activity, as follows : First, the bichloride itself; 
then the biniodide, the red oxide of mercury, calomel by precipitation, calo- 
mel by sublimation, the protiodide, and lastly metallic mercury. The prot- 
iodide is usually regarded as more active than it really is, because, according 
to the author, when prepared according to the method of the French Codex, 
it always contains, as an impurity, more or less of the biniodide, sometimes 
amounting to eight, or even ten per cent, of its weight. 

The author directs the attention of the profession to two facts in this con- 



1856.] Mialhe, Chemistry applied to Physiology and Therapeutics. 173 



nection, which are very important in a medico-legal point of view : first, that 
corrosive sublimate may exist in the dead body, in cases of poisoning, and 
not be detected by the usual tests ; and secondly, it may be detected in the 
body when it has not been administered during life. 

" The method usually adopted by chemists," he says (p. 463), " to detect cor- 
rosive sublimate in an aqueous solution, is to extract it with ether. Now, we 
have ascertained that corrosive sublimate, when accompanied with a notable 
quantity of binoxide of mercury and an alkaline chloride, will not dissolve in 
ether ; such is the mixture which is produced by the addition of a few drops of 
a fixed alkali to an alkaline chloro-hydrargyrate — that is to say, to a solution 
containing, at the same time, corrosive sublimate and an alkaline chloride." 

The possible detection of corrosive sublimate in the body, when none has 
been taken by the stomach, results of course from what has already been said 
of the transformation of all the mercurial preparations by the alkaline chlo- 
rides of the intestinal fluids. 

In the remaining chapters there are many interesting observations on the 
preparations of silver, the fixed oils, and vegetable alkaloids, the localization 
or stagnation of poisons, compatible and incompatible substances, pharmaceu- 
tical preparations, and the special mode of action of caustics, astringents, vesi- 
cants, purgatives, &c. The whole of this portion of the treatise is extremely 
suggestive; and though some of the author's conclusions may appear to be 
founded on too slight grounds — as, for example, what has been already quoted 
in regard to the preparations of iron — all of them are deserving of attention, 
and many will probably be more thoroughly established at some future time. 
The only danger, in this kind of study, lies in anticipating too confidently 
what reactions will take place in the animal fluids from what we know of their 
separate ingredients. It cannot be too constantly remembered, that it is im- 
possible to foretell what will be the reaction of any chemical substance in an 
animal fluid. So many unexpected results have already been obtained from 
direct observation in this particular as to show the extremely uncertain cha- 
racter of inferential conclusions; and we cannot better express the present 
and future requisitions of the science, in this respect, than by quoting M. 
Mialhe' s own words : — 

"Chemical reactions do not take place with such simplicity and precision in 
the interior of organized bodies as in the experiments of the laboratory. The 
human body is not an inactive capsule, a simple test-tube, without influence 
upon the phenomena which take place in its interior. It is, on the contrary, 
an exceedingly complicated and movable organization, all of whose conditions 
and elements must be investigated, ascertained, and reunited, before we can 
properly appreciate their influence upon any new combinations which may 
arise ; otherwise it is impossible to establish a single reliable conclusion. It 
is by too often forgetting these principles, and by misconceiving the composi- 
tion of the animal solids and fluids, that we have sometimes retarded science 
rather than advanced it, while making a hasty application to physiology of 
incomplete chemical ideas." J. C. ]3. 



No. LXIIL— July 1856. 12 



174 



[July 



BIBLIOGRAPHICAL NOTICES. 

Art. XIII. — Proceedings of American Medical Societies : — 

1. Proceedings of the South Carolina Medical Association, at the Extra Meet- 
ing in Columbia, July 5, 1854, and of the Annual Meeting in Charleston, 
Feb. 5, 1855. 8vo. pp. 104. 

2. Transactions of the South Carolina Medical Association, at the Extra Meet- 
ing in Greenwood, July 18, 1855, and at the Annual Meeting in Charleston, 
jFefc. 6,1856. 8vo. pp. 54. 

3. Transactions of the Sixth Annual Meeting of the Medical Society of the State 
of North Carolina, held at Salisbury, N. C, May, 1855. 8vo. pp. 40. 

4. Transactions of the State Medical Society of New York, at its Annual Meet- 
ing, Feb., 1856. 8vo. pp. 254. 

5. Proceedings of the Convention and of the Medical Society of California, held 
in Sacramento, March, 1856. 8vo. pp. 36. 

1. The proceedings of the Medical Association of South Carolina evince a 
laudable anxiety on the part of its members to cultivate assiduously the field of 
observation within their respective circles of practice, and to present the result 
of their labours as a contribution to the common fund of medical knowledge. 

The communications presented at the several meetings of which the volumes 
before us comprise the Transactions, are replete with practical details of great 
interest and value. To a few of them, it may, perhaps, be objected, that too 
much space and prominence are given to disquisitions of a purely theoretical 
character. It is very certain that the chief value of the contributions made to 
the several State and County Medical Societies, throughout our country, will 
be in proportion as they present a faithful record of the personal experience 
and observations of the physicians of each locality, in reference to its prevalent 
diseases — their character, progress, terminations, and treatment, compared with 
the topographical peculiarities of the locality ; the season at which the diseases 
were severally observed ; the meteorological phenomena that preceded and 
attended their occurrence; the general character of the population — its pursuits, 
habits, and condition — and, especially, of that portion of it which appeared to 
be the most predisposed to suffer from the endemics of the place, or from any 
epidemic with which it may have been visited. It is only from a series of 
observations of this character, carefully recorded, year after year, that we are 
to derive the materials to serve as the basis for a correct natural history of dis- 
eases — embracing their etiology, characteristics, progress, and terminations — 
and from which may be constructed satisfactory views of their pathology, pro- 
phylaxis, and therapeutics. 

The first communication comprised in the proceedings of the South Carolina 
Association is on typhoid dysentery, by Dr. R. W. Gibbes. 

Dr. G. commences with the remark, which has also been made by other phy- 
sicians, that typhoid disease has, of late, greatly increased in the State, though 
the mortality from it has been less than in the Northern States. 

"Within twenty years/' he remarks, "typhoid pneumonia has extended in 
all directions, and may now be found in all localities, and at all seasons. In 
the early part of my practice, I well remember, that for eight or ten years I 
never saw a case on a high land plantation, nor at any season than winter, 
while there has been a gradual extension from the swamps and creeks, where 
I had patients by hundreds, to the driest and most salubrious uplands, and to 
the town, in all sorts of weather, even in the midsummer heat, or the pleasant 
time of spring and autumn. We have yet to learn what is the cause of this 
and its kindred disorders. As so many different localities are affected, with 



1856.] 



Proceedings of American Medical Societies. 



ITS 



every variety of soil and cultivation, the greater probability is that atmospheric 
influence is more concerned in their production and propagation, than an 
emanation from the soil. Possibly electrical changes in the air and the earth 
have a more important influence than is usually allowed, while diet and habits 
of life are also to be considered." 

Dr. Gibbes gives the following as the characteristic symptoms of typhoid 
dysentery : — 

"It comes on with symptoms of depression and debility, not accounted for 
by a looseness for a day or two, with small discharges of bloody mucus, and a 
substance resembling a mass of brain and blood beat together; florid at first, 
but soon acquiring, in bad cases, a bluish appearance, reminding one of a mass 
of placenta. There is but little fever, and, in the worst cases, none ; that is, 
heat of skin and increase of force in the pulse ; where this is the case, I con- 
sider the disease less dangerous ; the pulse is quick but soft and relaxed, as in 
typhoid pneumonia, the breathing is but little disturbed. Usually, in the worst 
cases, the skin is soft and cool, often moist or damp, with a paleness or leaden 
aspect. The tongue is but slightly changed ; in some cases covered with a whitish 
fur, generally broad and flat, and not mote red than usual. In no case have I 
seen the sharp-pointed, acute, intensely red, raw beef-looking tongue, of acute 
inflammatory dysentery. The irritability of the rectum is very great, with dis- 
tressing tenesmus, with twelve to twenty stools in twenty-four hours. In some 
cases there is persistent irritability of stomach during the whole course of the 
disease, in others, a soreness and pain in the iliac region, intense at times, 
but not always present. After a few days, tormina from flatus is a distressing 
symptom." 

"Nothing is said as to the average duration of the disease nor the mortality 
produced by it, and in regard to the treatment which was found most successful 
in its management, we are left to draw our conclusions from the history of three 
cases which are presented somewhat in detail. The principal remedies em- 
ployed in these were opiates, astringents, and stimulants, with the oxide of 
silver and a milk diet. In children, Dr. G. states, that he has found the disease 
readily controlled by enemata of nit. argent. 10 grs. to one ounce of water, 
repeated every third or fourth hour, with the oxid. argent, and opium by the 
mouth. In some protracted cases he has given, with advantage, the tincture 
of cantharides, which is a favourite remedy with his friend, Dr. Trezvant, in 
cases attended with depressed nervous energy. In all his cases Dr. G. gave, 
freely, mint-toddy or port-wine negus, with solutions of gelatin, chicken-broth, 
or milk, for diet; articles, he remarks, presenting more nourishment in less 
compass than vegetable fuod, and of a kind more easily digested. 

The three cases, the histories of which are given in the communication before 
us, were, we are told, the only fatal ones seen by Dr. G., but as no mention is 
made of the entire number of cases treated by him, the statement affords us no 
clue to the general mortality of the disease. 

The next paper is entitled a "monograph" on typlioid fever, by Dr. J. McF. 
Gaston, of Columbia, S. C. As this monograph purports to present facts and 
deductions in reference to the particular form of disease of which it treats, 
derived from the personal experience of the writer, it is necessarily one replete 
with no trifling amount of interest. Disregarding the theoretical disquisitions 
to which so large a portion of the paper is devoted, we shall endeavour to give 
a brief account of such parts of it as have a direct practical bearing. 

After noticing the tendency to an increased typhoid character in the diseases 
of his vicinity, Dr. Gaston remarks, that he recognizes typhoid fever as an 
essential or primary affection — the several local lesions occasionally found asso- 
ciated with it — whether of the intestines, brain, or lungs, etc., being viewed bv 
him as purely secondary or symptomatic. 

Premising a general history of the proper characteristic phenomena of typhoid 
fever, Dr. G. proceeds to describe several types of the disease, " not specially" 
coming under the general description, and, " perhaps, not included in the his- 
tory of symptoms usually given in books of practice." 

The first of these types is a fever of low grade, with hot and dry skin ; with- 
out disturbance of the brain or bowels; with the peculiar typhoid pulse, of only 



176 



Bibliographical Notices. 



[July 



moderate acceleration. The distinctive features of the pulse of typhoid fever, 
Dr. G. describes as a peculiar, quick, jerking movement of the artery when 
compressed by the finger. Without this peculiarity of pulse all the other 
symptoms, usually enumerated in connection with the disease, may be pre- 
sent, without, in the estimation of Dr. G., constituting a case of genuine 
typhoid fever; but, with this manifestation of irritability in the systolic and 
diastolic action of the heart, he would recognize the fever were all other traits 
undeveloped. 

"It is, then," he adds, "with such a pulse as this — quickness, independent 
of frequency — a jerking propulsion of the blood with a perceptible cessation 
between the pulsations, however frequent, and, at the same time, a fixed uni- 
formity, without much tension or force, that I associate the idea of typhoid fever. 
When a hot dry skin is associated with this description of pulse of moderate 
frequency, and yet without any special local determination, it must be classed as 
typhoid fever, and, accordingly, I include it, although differing from the ordi- 
nary acceptation of the books. This may progress, and the patient scarcely be 
confined to bed. A listless, languid, good-for-nothing impression is felt, or 
there may be a lively appreciation of surrounding scenes, and more than ordi- 
nary loquacity, connected with a restless activity of body, but inability to 
undergo much labour or exercise, without great fatigue and prostration. Both 
these conditions will be found associated with an abnormal state of the nervous 
system, and dependent on debility, or want of proper action in the cerebro-spinal 
centre." 

This Dr. G. regards as the primary type of typhoid fever. The second type 
is one in which the surface of the body, and especially the extremities, is below 
the natural temperature, and dry; with a pulse decidedly small, feeble, and 
frequent; stupor; torpid bowels; dark brown, coated tongue, with red edges 
and tip. The disease apparently verging upon a malignant condition. 

A third type is that in which bilious remittent fever, early in the attack, 
verges gradually into a continued form, and the tongue becomes red at its edges 
and tip, and covered on its upper surface with a dry brown fur. This form of 
fever, Dr. G. holds, must be regarded, both as to its pathology and treatment, 
as genuine typhoid fever ; the difference in origin not necessarily constituting 
a difference in the nature of the pathological condition produced. 

Dr. G. confesses his inability to throw any light on the etiology of typhoid 
fever. It occurs, he remarks, on the plains and in the valleys ; amid the highest 
mountain settlements, and in the boggy marshes ; in well-ventilated apartments, 
and in narrow confined cells ; among well-fed luxurious men of leisure, and 
the robust plain living labouring classes ; in males and females, whites and 
blacks. And yet, when once developed, we know that it is aggravated by 
certain conditions and mitigated by others, which is a circumstance of great 
practical importance in reference to its treatment. Dr. G. does not consider 
the disease contagious, though he believes it may become, in some instances, 
infectious, by the accumulation of morbid secretions and a vitiated atmosphere 
about the person of the patient. 

The author's views of the pathology of typhoid fever are not very clearly or 
fully expressed. He would appear to consider the disease as the effect of some 
depressing influence, the primary action of which is upon the cerebro-spinal 
axis, from whence he traces the depression of nervous energy characteristic of 
the premonitory stage. 

" We are thus enabled," he remarks, "to afford a rational explanation of the 
whole train of disturbances, and to apply a treatment which will obviate any 
serious result in most instances. This may be reckoned an hypothesis, but, if 
it be one which meets all the conceivable forms of the disease, and which proves 
itself in practical results, it must strengthen our belief in its correctness. I 
am aware that some abstruse allusions to the connection of this fever with the 
ganglionic system have been presented to the public. But, the symptoms pre- 
sented at the outset of the disease are undoubtedly those of general nervous 
depression, afterwards of irritation, and subsequently prostration, and in refer- 
ring them to the cerebro-spinal axis as a source, I am but pursuing a natural 
channel of association." 



1856.] 



Proceedings of American Medical Societies. 



177 



In proceeding to the treatment of typhoid fever, Dr. G. considers the reme- 
dial measures as they are adapted to, 1st, the premonitory stage ; 2d, the stage 
of development ; 3d, the progressive stage ; 4th, the decline ; and 5th, the con- 
valescence. 

In the first stage, he trusts mainly to a solution of bicarbonate of ammonia in 
gum-water, administered every hour or two during the day, with a Dover's 
powder at night to insure rest. Other stimulants, he remarks, may, doubtless, 
be used with advantage, but the carbonate of ammonia is the article he has 
relied upon in the premonitory stage, and it is with much confidence he recom- 
mends its use at this period of the disease. 

In the second stage, when the disease has become fully developed, any attempt 
to arrest the course of the disease will be futile, but we must look for its con- 
tinuance for a period of perhaps twenty-one days, or even longer. During this 
period, Dr. G. proscribes bloodletting, whatever may be the apparent indication 
for its employment; active purgatives, however torpid the bowels ; all nauseat- 
ing and relaxing remedies ; the constitutional effects of mercury to the extent 
of producing salivation ; the discharge from a blistered surface, even when 
counter-irritation may be demanded ; and, in short, everything that can have 
a tendency to lower the vital energies of the patient. 

The treatment recommended is careful and assiduous nursing; the abstrac- 
tion of the patient from all depressing influences, moral and physical ; the 
moderate and cautious administration of stimulants ; and a farinaceous, well- 
regulated diet. When there is bilious complication, Dr. G. directs blue mass, 
with Dover's powder, assisted, if necessary, in its operation by a gentle enema 
given next day. When costiveness is present, he gives castor oil, combined 
with spirits of turpentine. Cooling applications are directed to the head. 
When there is abdominal distension, attended with tenderness on pressure over 
the right ilio-csecal region, benefit will be derived from frictions to the part 
with camphorated spirits of turpentine. When the tongue is dry, red, and 
glazed, the best remedy will be spirits of turpentine, in small doses, internally, 
combined with camphorated tincture of opium and gum Arabic. When diar- 
rhoea occurs, it is to be checked by the acetate of lead and opium by the mouth, 
and, as an enema, incorporated with starch. As a stimulant and tonic, Dr. G. 
employs quinia in this stage of the disease, giving it in the dose of from half a 
grain to a grain, two or three times in the day. In the abortive practice, by 
the employment of large doses of quinia, at short intervals, he has no confi- 
dence ; he has tried it faithfully and courageously, but with only partial suc- 
cess in any case. 

About the ninth day a crisis usually occurs, and the disease then assumes a 
milder or a more aggravated character. In the first case a gentle stimulus, such 
as cracker panada, with the addition of sound Madeira or Port wine, and the 
maintenance of the bowels in a regular condition by enemeta of corn-meal 
gruel, is the chief treatment that will be required. But if the disease augments 
in violence, more active stimulation will be demanded. " It is a matter 
of much consequence," Dr. G. remarks, "to be regular in the administration 
of stimulants at this stage of typhoid fever. The condition of the patient 
should determine the times and quantities, and the increase should be made 
as the prostration ensues, with the progress of the disease. 

" If cerebral disturbance persists, in the progressive stages, a blister to the 
scalp, as a counter-irritant, will sometimes prove advantageous. But the indi- 
cations of inflammation should be very positive to justify its application, as 
the mere functional disturbance will not be relieved by this mode of treatment, 
and may be aggravated. It is better to err on the safe side, and dispense with 
it in a doubtful case. I have seen uneasiness and jactitation, with a peculiar 
stare, and contracted state of the muscles of the face, giving an unnatural ex- 
pression of countenance, entirely relieved by a free administration of brandy. 
These symptoms are frequently thought to be connected with inflammation of 
the brain, but they are really the result of nervous depression, the want of a 
due excitement of the brain ; and when the equilibrium is restored by the in- 
fluence of the stimulant, the patient becomes composed, and all the functions 
are performed with greater harmony." 



178 



Bibliographical Notices. 



[July 



The patient should be properly nourished. Dr. G. prefers, as a general rule, 
farinaceous articles, reduced to a fluid consistency. When the bowels are not 
disturbed, ripe fruits may be allowed, and mucilaginous drinks. Large 
draughts of water, iced or otherwise, have been invariably found to do harm. 

" In the progress of typhoid fever, it is essential that the sick-room should be 
freely ventilated, and that everything about the bed and person of the patient 
be often changed for dry, fresh, and clean articles. The skin should be 
cleansed with soap and water every two days, and rubbed with a coarse 
towel afterwards, until a glow is established on the surface. All the changes 
of apparel, and the removals from bed, should be attended to by the nurse, with 
competent assistants, and the effort to do even slight things should be pre- 
vented, as the strength of the patient is more apparent than real." 

"As the fever begins to decline, the husbanding of the strength is demanded 
by every means we can avail ourselves of. The patient must not be allowed 
to sit up too soon. Profuse sweating must be restrained by frictions with dry 
flannel, on which may be dusted a small quantity of powdered mustard and 
alum. Coolness of the extremities may be obviated by sinapisms to these parts, 
or to the spine. Moderate but adequate stimulation is still demanded, with a 
carefully regulated diet. Dr. G. prefers the use of farinaceous articles until 
the fever has nearly disappeared, and the appetite has become strong, when he 
gradually introduces the animal juices, and the more tender articles of a solid 
kind. 

"At the close of the regular course of the fever, exacerbations sometimes 
occur in the afternoons, or perhaps without much uniformity as to time or fre- 
quency. We may give the quinia in the intervals to encourage this tendency, 
and continue it, in small portions, three or four times a day, as a tonic. Should 
night-sweats be present, the elixir vitriol may be added to the quinia, and 
given in conjunction with Port wine. The paroxysms will usually yield under 
this course, and the patient will forthwith enter upon the stage of conva- 
lescence." " A stimulant, with proper attention to diet, is important for a 
considerable period after the fever has disappeared. Brandy, Port-wine, or 
Madeira may be used, but Dr. G. has found good French brandy most reliable 
in this debilitated condition." 

We have given, above, a brief outline of the views of Dr. Gaston in relation 
to the nature and treatment of typhoid fever. For details we must refer to the 
paper itself, which is well deserving of an attentive perusal. It is true, in 
many of his opinions, the author is very far from being orthodox, and employs 
the term typhoid fever in a much wider, though we think more correct sense, 
than that which has been given to it of late years. The typhoid fever of Dr. 
G. embraces a form of febrile disease, which, with various important modifica- 
tions, has, within a short time past, rapidly increased in prevalence through- 
out the United States. Of this form of fever the monograph before us will be 
found to furnish a very interesting, though by no means complete account. 

As a kind of appendix to the foregoing paper, Dr. Gaston presents some re- 
marks on the criterion for the employment of stimulants. 

The proper employment of stimulants as a therapeutic agent, the particular 
circumstances under which a resort to them is demanded, the extent to which 
they must be pushed, in any given case, in order that the favourable results 
they are adapted to produce may be obtained, and the indications for their dis- 
continuance, are questions of no trifling importance, but in relation to which 
there is a great want of unanimity of opinion among medical practitioners. 
Even as to the indications for the fulfilment of which a resort to them is de- 
manded, there is little or no agreement among our most authoritative therapeu- 
tists. Dr. G. believes that he has discovered a positive and unerring criterion 
by which the propriety or impropriety of the employment of stimulants in the 
treatment of disease may be decided. This criterion is the condition of the 
circulation in the capillaries of the surface, which he supposes to be an index 
of the condition of the capillary circulation throughout the body. 

If the colour of the skin, at a point where pressure has been applied by the 
finger, is slow in returning, it indicates a want of tone in the capillaries of the 



1856.] 



Proceedings of American Medical Societies. 



179 



surface, and, as Dr. G. infers, of the rest of the system, calling for a resort to 
stimulation, in proportion to the deficiency of tone thus indicated. 

" It is not," he remarks, "when the general cutaneous surface presents the 
most florid appearance that the lancet is best practised ; nor is it when the 
skin is wanting in colour that I would suggest stimulants. But, in either con- 
dition, there may be a debility, indicated by a torpor of the capillaries, when 
pressure is made by the end of the finger, and under such circumstances, I 
think, we will rarely be disappointed in resorting to a stimulant. Thus, we 
are not left to judge of the force, fulness, or frequency of the pulse, nor are we 
compelled to resort to tentative measures, of very doubtful propriety, but all 
may be satisfactorily determined, in the majority of cases, by a particular 
examination of the state of the capillary circulation. " 

Dr. G. wishes it to be distinctly understood that this criterion for the employ- 
ment of stimulants has not been sufficiently established by observation to en- 
able him to give any positive assurance as to its results. The subject is open 
for investigation, and he trusts that others will prove its importance in the treat- 
ment of all diseases to which stimulants are applicable. 

"This test for the application of stimulants/'' he adds, "appears simple, but 
it will require much careful comparison of the healthy with the diseased, of the 
strong with the weak, and much discrimination between diseases themselves, 
and their tendencies, to render it useful as a diagnostic. It will require judg- 
ment to profit by it in the way proposed, and yet I trust that all these diffi- 
culties may be overcome, and that it may prove an adjuvant to other means of 
discrimination, if not a complete index to the condition of the vital forces." 

On typhoid pneumonia, by Dr. R. S. Bailey, of Charleston. This paper is 
occupied, chiefly, by the history of two cases of the disease, to which are ap- 
pended a few practical remarks. 

The succeeding paper is an account of epidemic dysentery, as it appeared in 
the districts of Chester and Lancaster, S. C, during the years 1853-54, by Dr. 
Mobley, of Lancaster. 

This communication is one of considerable interest and value. We regret, 
however, that the author has neglected to notice any of the circumstances ob- 
served during the epidemic of which he is the historian, calculated to throw 
light upon the etiology of dysentery, and that he has furnished no statistics 
showing the number of cases observed, the class, age, sex, and colour of the 
persons attacked, and the amount of mortality produced by the disease. 

After very full details of the treatment pursued in the several types under 
which it presented itself in different cases, Dr. M. remarks: — 

"But the most important agent in the treatment of this epidemic, the remedy 
par excellence, was opium, without which all our efforts to control the disease 
would have been fruitless. I am persuaded that others have confined them- 
selves too much to the doses prescribed by custom, and have dreaded too much 
the poisonous effects to derive the full benefit of this drug in the management 
of dysentery. At any rate, the quantity which seems to have been given else- 
where would have fallen short of any visible effect on the disease as it appeared 
to us. It was an imperative necessity to check, or at least to moderate, the 
incessant purging, and, above all, to ameliorate the intolerable suffering from 
tormina and tenesmus, as the patient had been worn out and exhausted, and 
the vital powers had succumbed." " I have observed that small doses are 
more apt to excite the brain and nerves, while the larger seem to act as a seda- 
tive. Opium was also a grateful stimulant, particularly in the latter stages of 
the disease, maintaining the equilibrium of the circulation, and diffusing a 
general glow over the whole body. It thus enabled us to bleed, sometimes, in 
the early stage, where the pulse would not otherwise admit it. By subduing 
the erythism of the system, it secured us the chances of blistering, where other- 
wise it would not have been tolerated. But, above all, it gave us the stimulus 
of hope. In almost every stage of dysentery we have not so much the brain 
affected as great mental anxiety and despondency." 

In the next paper, Dr. J. McF. Gaston gives the description of an " abdominal 
spring pessary," with drawings illustrative of its construction and application. 
This pessary is a combination of the stem pessary with the abdominal sup- 



180 



Bibliographical Notices. 



[July 



porter ; the two being united by a spring, -which passes downwards from the 
front piece of the supporter, and curves backwards to be attached to the lower 
end of the stem pessary. The material of the pessary is silver, hollow within. 
Below it is a mere tubular stem, off inch diameter, which gradually enlarges 
as it ascends, terminating in a hollow bulb, depressed above and anteriorly, so 
as to form an oblique concavity, with a rounded rim 6| inches in circumfer- 
ence. In the depression above there is an opening, from which a tube passes 
downwards, and out at the lower extremity of the stem. The length of the 
pessary on its posterior face, from the rim of the bulb to the extremity of the 
stem, is inches, and on its anterior face 3-f inches. The difference of {ength 
on the two faces results from the obliquity of rim of the concave surface, and 
a slight curvature forwards of the upper portion of the instrument, correspond- 
ing with the axis of the pelvis. The largest diameter of the rim is from side to 
side; its front part is somewhat flattened and obtunded, to obviate collision 
with the rectum or bladder. An instrument of smaller dimensions may be 
used with good results when found better adapted to the condition of the parts. 
The upper portion has been also modified from the hollow bulb to a concavo- 
convex cup. 

The experience of Dr. G. with this apparatus has satisfied him that better 
results are attainable with its use than from any other means which have been 
resorted to for the relief of prolapsus uteri and the relaxation of parts con- 
nected with it. 

"When the apparatus is properly fitted to the person, and the pessary is 
introduced into the vagina, the neck of the womb rests in the concavity of the 
upper surface, and the organ is kept in its place by means of the spring at- 
tached to the stem, without any tension of the vaginal walls. In the use of all 
self-retaining pessaries, the vagina is so distended as to overcome its contrac- 
tile powers, and increase the liability to prolapse after the removal of the instru- 
ment. Such a result does not attend this modification of the instrument; the 
stem is so reduced in size that it causes no dilatation of the rugous coats of 
the vagina, or of the sphincter. The tube, which affords an outlet to the secre- 
tions of the womb, admits, also, of the introduction of medicated injections, 
which come in contact with the os tineas, and flowing over the rim of the pes- 
sary, are diffused over the entire lining membrane of the vagina. Thus the 
vaginal walls are contracted, and the broad and round ligaments are restored 
tb their proper tone, and retain the womb in its normal position. 

" The abdominal front piece takes off, to a great extent, the downward 
pressure of the intestines, and a radical cure is promoted, without the restraint 
and inconvenience which attend the ordinary treatment for prolapsus uteri. 
Instead of long confinement to the horizontal position, with its concomitant 
atonic condition of the physical organization, the patient may walk and take 
healthful exercise in the open air while the apparatus is worn/' 

The value of the apparatus just described must, of course, be decided by the 
results of experience. We should fear that more or less irritation will be pro- 
duced, in the various movements of the patient by whom it is worn, by the stem 
of the pessary and the external spring at the point where they are connected in 
the upper commissure of the vulva. We should rather expect also a downward 
pressure, rather than an opposite effect upon the intestines, and of course 
upon the womb, by the action of what Dr. G. demonstrates " the abdominal 
front-piece/' 

Cases of pseudoarthrosis, by Dr. R. W. Gibbes, of Columbia. Three cases 
are related. In the first, the ununited fracture was of the humerus, about 
three inches above the condyles. Perfect union was effected by friction of the 
fractured surfaces, at the end of six weeks. This case is replete with interest 
throughout. In the second case the ununited fracture was situated about the 
middle of the right femur. Union was brought about by inserting two steel 
needles into the unossified callus, and by them piercing and lacerating it freely, 
then allowing them to remain in for eighteen days. Union took place in about 
four months. In the third case there was an ununited fracture of both bones 
of the forearm ; union was effected at the end of eight or nine weeks, by a 
seton introduced between the fractured surfaces. 



1856.] 



Proceedings of American Medical Societies. 



181 



In the first case phosphate of iron, and in the second, phosphate of lime were 
freely administered, and Dr. G. believes had a favourable influence in promoting 
the union of the fractured bones. 

The volume closes with the Address of the President of the Association, deli- 
vered at the annual meeting in 1854. 

The address contains some excellent remarks on the importance of medical 
organization, and the means best adapted to elevate the character and promote 
the efficiency of the medical profession. 

There is one position assumed in the address to which, however, we cannot 
assent. It is, that the medical profession have no right to expect that any 
college should require every candidate for the degree of doctor in medicine 
be perfectly prepared to enter upon the practice of his profession, in all 
its various departments ; inasmuch, as to demand such a proper action for 
graduation would drive the students from its classes to those of other schools 
where they can procure the doctorate with less difficulty. Hence all that we 
can ask of any medical college is, that they shall make their examinations as 
rigid as they can be made short of driving away the students. 

The medical profession have interests which are paramount to the mere pecu- 
niary interests of any or all of the medical schools. They have an unquestion- 
able right to require of every college that those sent forth by it bearing its di- 
ploma should be precisely what that diploma declares them to be, individuals 
well instructed in the theory and practice of medicine. If, before conferring the 
diploma, they neglect to subject their graduates to an examination, sufficiently 
rigid to test their qualifications for its reception, they commit a fraud upon the 
medical profession and the public, and bring the doctorate into such contempt 
that it becomes no longer a distinction worth the trouble of acquiring. No 
school has a right to be governed by the will of its students, so far as to lower 
the grade of its examinations to adapt them to their incompetency ; nor can 
the medical profession be turned aside from its demands for a full and thorough 
education of all who would desire to enter its ranks, by any fear that a com- 
pliance with those demands shall thin the classes and curtail the income of 
any set of medical teachers. 

2. The Transactions of the South Carolina Medical Association, at its extra 
meetings in July, commence with a short but pertinent address by the Presi- 
dent, Dr. J. P. Barratt, on the objects of the Association, and the duty of its 
members to zealously co-operate in their accomplishment. 

Then follows a brief account of dysentery, as it has occurred, epidemically, 
during four consecutive years, in Orangeburg and the adjoining districts. The 
account was prepared by Dr. Salley. 

The disease, we are told, did not seem to select low, damp situations, nor 
was it of a more intractable character when it did occur in such localities. 
In 1852, it began in the most elevated portion of Orangeburg. 

The grave cases were always indicated by a foul tongue, high fever, frequency 
of pulse, great soreness over the abdomen, the urgency of the tenesmus, and 
the number of the evacuations, and if there were no other bad symptoms pre- 
sent, the rapidity of the pulse and rapid emaciation of the patient, were suffi- 
cient to excite anxiety for the result. Hiccup was not an unfrequent symptom, 
but of itself, was not regarded as a grave one ; but when connected with a low 
delirium, and a relaxed state of the sphincter ani, it was the immediate pre- 
curser of death. 

In the treatment of the epidemic general bleeding was inadmissible. Mer- 
cury Dr. S. found to aggravate the worst features of the disease. 

The most successful treatment, in the hands of Dr. S. and the physicians of 
his neighbourhood, was by saline purgatives in very minute quantities. The 
sulph. sodse was generally preferred, but not exclusively. 

" In mild cases, sulph. sodae, tinct. opii, each gj, in six ounces of water: a 
tablespoonful every third hour, is a very good prescription. The super tart, 
potass, in ten grain doses, with one drachm tinct. opii camph. is very much such 
a formula as the first, and equally efficacious. Dr. S. has used, more than any- 
thing else, a powder, made by substituting the sulph. sodae for the sulph. pot. 



182 



Bibliographical Notices. 



[July 



in the Dover's powder, and adding two drachms of prepared chalk. The dose 
is from five to ten grains." 

Dr. S. notices, also, a combination of bitart. potass., opium, and ipecac. ; ten 
grains of the former to half a grain of each of the latter, as an admirable 
remedy, both for its efficacy and convenience. It may, he remarks, be safely 
relied on in the first stage of a large proportion of cases. 

The pulv. nux vomica Dr. S. would not recommend when the stools are all 
blood, or serum, or blood suspended in serum, but has great confidence in it 
when the discharges are composed of blood and. mucus intimately combined, 
or of mucus alone; discharges that are always attended with a great deal 
of tenesmus and pain. 

The spirits of turpentine he considers to be a very efficacious remedy in 
cases attended by frequent discharges of fluid blood. Of the nitrate of silver 
he cannot speak favourably in the first stage of the disease. 

In some bad cases he has known the patient suffer much from dysuria, for 
which distressing symptom he knows no better remedy than frequent large 
injections of cold water. 

" The treatment of infants and children must be somewhat modified. They 
bear opiates so badly, that if care be not taken, the remedies will destroy more 
than they cure. Hyoscyamus should be substituted for opium in all these cases. 
From half to a grain of hyoscyamus, combined with from three to five grains 
of sup. tart, pot., I have found to be the best and safest prescription I have 
ever used. A child is often quieted by allowing him to sit in a tub of water, 
and by applying warm fomentations to the abdomen." 

In the second stage of dysentery, when ulceration has probably occurred in 
the large intestine, there is great emaciation ; very frequent pulse ; sometimes 
cool extremities, with the rest of the surface hot and dry; a dry and often 
glazed tongue; the discharges are composed of blood and mucus, or they are of 
a purulent appearance or contain particles of pus. The best remedies in this 
stage Dr. S. has found to be the spts. of turpentine and nitrate of silver. Iodine, 
he has reason to believe might be advantageously administered. 

Dr. Salley presents a description of a very simple, cheap, and convenient 
fracture bed. It is composed of two ordinary carpenter's trestles, upon which 
are nailed boards of the requisite length, to support a good wool mattress, covered 
with a blanket and sheet. A frame of scantling is then to be made, the sides 
of which are to project two feet beyond the bed. This frame is to be covered 
by a strong piece of cotton bagging, securely tacked to the side pieces. This 
is to be covered with a quilt and sheet, through which and the bagging, in a 
proper position, a hole is to be cut. The frame is to be laid upon the bed, and 
upon it, the patient. When the latter has a call to evacuate his bowels or 
bladder, or when it is desirable to cool the parts heated by contact with the 
bed, two assistants can remove the frame, with the patient on it, and place 
beneath its two ends a trestle two feet higher than the bed, by which it will 
be supported as long as is found convenient or necessary. 

Dr. Bailey, of Charleston, read an entertaining essay on the want of medical 
faith and the evils thence resulting, whether the want of faith exist in the patient 
as to the efficacy of medicines generally, or those employed in his particular 
case, or as to the skill of his physician, or the want of faith be in the physician 
as to his competency, or his knowledge of the true nature of any case for which 
he maybe called upon to prescribe. The essay, though it displays neither any 
great depth of reasoning nor aptness of illustration, is, nevertheless, replete 
with common sense and every day truths too apt to be overlooked by the mem- 
bers of our profession. 

The annual meeting of the Association in 1856, was opened by some pertinent 
remarks on the condition, importance, and future action of the Association, 
and the propriety of the entire medical corps of the State lending their co-opera- 
tion in the furtherance of its objects. 

To this succeeds an oration by Dr. E. T. Miles. The theme of the orator is 
Medical Association, its scope and advantage — the benefits derived from it by 
the individual members of the profession, by the cause of scientific and practical 
medicine, and by the best interests of society at large in the augmentation of the 



1856.] 



Proceedings of American Medical Societies. 



183 



means for the prevention and control of disease. Most ably is this interesting 
theme discussed and enforced, and most eloquently are the physicians of South 
Carolina urged to render it, by their acts, the efficient instrument for obviating 
the enfeebling separation of mind from mind, and for enabling our profession 
to stand forth, with dignified strength, among the formative elements of society, 
and prevent the intelligence, philosophical bias, and noble aspirations engen- 
dered by the pursuits and objects of the true physician to struggle, with divided 
energy and object, against the forward presumption of the deceitful and secret 
arts of ignorance and imposture — to make it the means of marshalling the ranks 
of those enlisted in the cause of legitimate medicine, with renewed vigour, to 
the work of enlightenment and amelioration. 

Two interesting cases are detailed by Dr. Robert Lebby. The first is a case 
of rupture of the bladder, on its posterior surface, a little below the fundus. 
The patient was a strong, healthy man, in the vigour of life. On descending 
a flight of six steps, the heel of his right shoe caught on the edge of the first 
step and precipitated him forwards; he made a violent exertion to save himself 
by which he was hurried, without falling, to the bottom of the flight of steps. 
No inconvenience was experienced for some ten or fifteen minutes, when the 
patient was seized with a violent pain in the epigastrium, extending to the 
umbilicus, and attended with swelling of the abdomen. In the course of the 
ensuing night, he voided per urethram about a gill or more of pure arterial 
blood. The next day his countenance was pallid and anxiously distressed, 
surface cold and clammy ; great tumefaction of abdomen, hard and unresisting ; 
pulse thread-like, feeble, and frequent ; voice husky and hollow ; intellect clear ; 
great restlessness. The patient survived the accident nearly five days. On 
examination after death the rupture of the bladder was detected ; the cavity of 
the abdomen was filled with urine and extravasated blood; no mention is made 
of peritoneal inflammation. 

The second case is one of tubal pregnancy, with rupture of the right Fallo- 
pian tube. The sac, entire, about the size of a walnut, and filled with a limpid 
fluid in which floated a foetus, of between three and four months' development, 
had escaped into the cavity of the abdomen, where it was surrounded by a 
coagulum of blood of large size. 

Dr. L. details, also, the history of three other cases of the accident that have 
occurred in Charleston within the last thirty years. 

"It will be observed," the Dr. remarks, " that there is a striking similarity 
of symptoms in all of the four cases ; and the reference hereafter, may enable 
the practitioner to form somewhat of a clear diagnosis of so terrible a calamity. 
"While our art could afford no relief, yet the progress in medical research and 
advancement may determine positively the character of the accident." 

He informs us that the symptoms of the case seen by him led him to believe 
it to be an attack of cholera, for which it was treated. 

"The cramp in the abdomen and extremities; the serous fluid thrown up, 
with the alvine dejections of a simliar character, sustained such a diagnosis. 
These symptoms agree, in part, with Dr. Simon's case. There was, likewise, 
no tympanitis, and very little tenderness over the stomach; the abdomen was 
not swelled. In both Dr. Simon's and Holbeck's cases, there was no tympanitis, 
but excruciating pain when the abdominal parietes were touched. In Dr. L.'s 
case there were no positive symptoms, except the pallid lip that indicated 
hemorrhage, and this not more so than he has frequently seen in cholera pa- 
tients. In Dr. Simon's case, the tube, between the place of rupture and where 
it enters the uterus, was nearly obliterated. This was not so in Dr. L.'s case, 
and, he concludes, was not so in Drs. Holbeck or Mitchell's, although they are 
silent on the subject." 

A report of the committee on registration follows, with the draft of a bill to 
be presented for enactment to the legislature of South Carolina. The objects 
of this bill are thus concisely and accurately stated. 

" 1st. To ascertain the relative number and proportion of births, deaths, and 
marriages, in order to ascertain the progress and increase of the population. 

"2d. The causes of death; so as to be able to trace the operations of natural 
and physical causes on the health of the inhabitants. 



184 



Bibliographical Notices. 



[July 



"3d. The season of the year, and duration of illness, and locality, where 
certain diseases prevail, so as to suggest means for abating them. 

"4th. The age, sex, condition, colour, nativity, and occupation; in order t} 
know how these various circumstances influence marriages, births, and deaths. 

"5th. With a proper and complete record of these events in human life, are 
involved great public and private rights, such as claims to property, etc. etc." 

The physicians of nearly every State appear to be impressed with the im- 
mense importance of securing a regular and continuous registration of the 
births, deaths and marriages which occur within its borders, and are moving 
with energy and zeal to secure its accomplishment. When will the profession in 
Pennsylvania awake from their apathy in relation to this matter, and be willing 
for their own and the public good, to give the slight amount of labour required 
at their hands for carrying it into effect. When the public shall become fully 
aware of how materially their interests will be promoted by a registration law, 
physicians will be compelled to do what they ought to be the first voluntarily 
to perform as an act of duty they owe to themselves and to the public. 

A unique case of dislocation of the2?ateUa is reported by Dr. Wragg. It oc- 
curred in a negro, who, while engaged in loading lumber upon a boat, was 
caught by a loaded car, whilst in motion, and jammed against the cross-sticks 
on which the piles of lumber rested. A complete revolution of the patella on 
its longitudinal axis had taken place, so that its outer edge corresponded, nearly, 
to the inner edge of the articulating surface of the femur ; its anterior face was 
turned backwards, and rested on the articulating surface of the femur; its inner 
edge looked outwards and a little forwards, forming a projecting edge in front 
and on the outside of the joint; and its posterior or articulating face was under 
the skin, looking forwards, with a slight inclination backwards. 

Having ascertained that, in coming to its new position, the inner edge had 
been forced forwards and then outwards, the reduction was readily effected, by 
the thumbs of both hands being placed on the outer and under edge of the pro- 
jecting border of the patella, while the index and middle fingers were pressed 
against the other border, in a direction outwards and backwards, and force being 
applied with the view to roll the bone over into its place. The first effort failing, 
a bystander was directed to pass his hands under the knee-joint, and make 
forcible and intermittent flexion of the leg. In a moment, the bone performed 
an evolution, slipped into its place, and the man rose up and walked. He ex- 
perienced no further inconvenience ; the ligaments, cartilages, and investing 
membranes of the joint having received no injury from the extensive displace- 
ment of the patella. 

3. The Transactions of the sixth annual meeting of the Medical Society of 
the State of North Carolina present, first, a report on surgery by Dr. 1ST. J. 
Pittman. It comprises a series of interesting cases, that occurred in the prac- 
tice of the reporter. Among these we would notice, especially, a case of vesico- 
vaginal fistula, of eight months' standing, operated upon according to the method 
of M. Jobert, with very promising success. A case of compound fracture of the 
left scapula, from a violent blow on the shoulder, treated by Desault's apparatus 
for fractured clavicle. A perfect union of the fracture ensued, without deformity 
or any impediment to the motions of the arm remaining, and a case of perineal 
fistula, of five years' standing, operated on by freely laying open the sinuses, and 
removing as much of the integuments as seemed advisable. Dressings of lint 
and cold water were applied, and perfect rest enjoined. The case is still under 
treatment, and, so far, doing well. 

This report is followed by an address, delivered by the same gentleman, on 
the " Nature of Auscultation and Percussion as a Means of Diagnosis in Dis- 
ease." The subject is treated with great ability and clearness. The advan- 
tages to be derived from these means, for the physical investigation of disease, 
are strongly insisted on, andthe necessity of every practitioner becoming familiar 
with their mode of application pointed out. With great propriety, Dr. P. 
points to the necessity of the introduction into our language of a plain nomen- 
clature of auscultation. It would, certainly, greatly facilitate a more general 
resort to it in the investigation of the diseases of the chest and its viscera. 



1S56.] 



Proceedings of American Medical Societies. 



185 



The next report is by Dr. W. H. McKee. It comprises a case of confluent 
smallpox, of a very bad character, in which Dr. M. was induced to employ the 
muriated tincture of iron, from having seen it used with so much success in 
erysipelas. 

" The patient," he remarks, " may have recovered without anything, but as 
his case was a bad one, and he recovered so promptly, I thought it not amiss to 
mention it here. Xeither the pain in the head nor the delirium should deter 
the physician from giving the iron, either in smallpox or erysipelas, as I can 
safely say it is by far the best remedy I have ever used in phlegmonous erysi- 
pelas." ' ; If, on further trial, the muriated tincture of iron should be found to 
possess as much therapeutical virtue in the treatment of smallpox as it does in 
the management of erysipelas, it will relieve the profession, as well as the 
community, of some of its terrors." 

Dr. M. also reports three cases of puerperal convulsions, in which injections 
of spirits of turpentine appeared to have the effect of suspending the convul- 
sions, and, at the same time, in producing labor when the functions of the ute- 
rus were apparently suspended. 

In reference to the dysentery that prevailed, with the ordinary symptoms, 
more or less, in Raleigh, and the surrounding country, throughout the year 
1854, Dr. M. remarks, that the treatment most successful in his hands was the 
saline and opiate. He used very little calomel, or mercurials of any kind, as 
they appeared rather to irritate than soothe the disease. In all cases of long 
standing, he found the nitrate of silver, in grain doses, with a half to a grain 
of opium, every four or six hours, to give prompt relief. 

The scarlet fever and measles, which prevailed during the same period, were, 
in some instances, so hybrid in their appearance, that it was difficult, in the 
early stage of the attack, to discriminate between the two, and it was only in 
the sequel that the real character of the disease was developed. In some cases, 
the scarlet fever assumed, in its initiatory stage, a congestive type, resembling 
a chill, accompanied by gastric fever. The patient, instead of presenting a 
scarlet appearance, would be pale, labour anxiously for breath, and vomit ; in 
a short time, the bowels would become relaxed ; cold, clammy perspiration, and 
death, soon closed the scene. Dr. M. saw some few cases of a putrid or malig- 
nant character. 

" The winter of 1854," Dr. M. informs us, " was the driest and coldest known 
for years, and yet. pneumonia prevailed to a much more alarming degree than 
it had for some time. About the middle of January, 1855, it first appeared as 
an epidemic. It was not confined to any particular class of citizens, but pre- 
vailed generally, attacking, in some instances, nearly all in a family, and, in 
others, only one. In many cases, the patient would be taken suddenly, and 
complain of violent pain in the head, which would be followed by stupor, cold 
extremities, hot head, leaden appearance of the skin ; pulse small, quick, 120 
to 140 ; breathing quick and short, bowels as often loose as bound. If nothing 
was done for the patient at this stage of the attack, he would gradually rouse 
up in twelve hours, and often express himself as feeling much better, and ask 
for something to eat, and, if allowed to do it, would eat a hearty meal ; but 
soon after, fever would set in, with delirium, and, in some instances, raving. 
Most of the cases Dr. M. saw in the country, were at this stage of the disease. 
The treatment consisted in giving a dose^of Epsom salt in some warm, red pep- 
per tea. This, in a short time, would vomit freely, unloading the stomach, 
and operating several times on the bowels. Afterwards, a decoction of seneka 
and liquorice-root was given, in tablespoonful doses, every two hours ; flaxseed 
tea, acidulated with lemon-juice, being allowed freely as a drink, with, occa- 
sionally, a teaspoonful of equal proportions of oxymel and compound syrup of 
squills, to aid expectoration, and, at night, a dose of morphia, to procure sleep. 
If the pain in the side was very acute, cups were applied. The head was only 
relieved by shaving the top, and applying a blister. Some other cases Dr. H. 
treated with quinine and hive syrup, as an alterant and expectorant. In every 
instance, he had to use stimulants at some stage of the disease. In not a 
single instance was he able to employ the lancet. If the patients survived the 



186 



Bibliographical Notices. 



[July 



ninth and eleventh day, they invariably recovered. The deaths took place, 
generally, on the fifth, sixth, or ninth day of the disease/' 

Speaking of chronic intermittent fever, usually accompanied with a chloro- 
anemic condition, and indications of dropsy, and enlarged spleen, Dr. M. states 
that quinine and muriated tincture of iron will, in most cases, effect a cure, if 
given three times a day for two or three weeks. The combination will some- 
times be rejected by the stomach, especially in children. When this is the case, 
he has found the following equally successful : grains 60 of quinine, and grains 
180 of phosphate of iron, intimately combined, and divided in 36 parts, of 
which one is to be given to an adult, in syrup or water, three times a day, and 
to children, in doses adapted to their age, until the whole is taken. 

These Transactions close with the valedictory address of the President, Dr. 
J. H. Dickson. Its subject is the dignity, scope, and importance of the pro- 
fession of medicine; a theme which the writer enforces with commendable zeal, 
and no little force and eloquence. 

4. The Transactions of the State Medical Society of New York open with an 
able eulogium on the life and character, and professional labours, of Dr. Theo- 
dric Romeyn Beck, by Dr. F. H. Hamilton. It presents a very interesting 
memorial of one distinguished by his indomitable perseverance, his ardent 
devotion, his honesty of purpose, and excellent talents, who, daring his lifetime, 
occupied a high rank in the scientific world, and whose name will be handed 
down to posterity, if by no other of his publications, by, at least, his Elements 
of Jurisprudence. 

The second paper is a report on " Tuberculosis and Tubercular Pneumonia," 
by Dr. C. B. Coventry. Though short, compared with the vast importance of 
the subjects embraced in it, it is, nevertheless, replete with valuable hints and 
suggestions, and presents a nearer approach to a correct pathology of what 
have been denominated tuberculous diseases — or those associated with tubercu- 
lous depositions — than that which has heretofore been taught in the generally 
received practical treatises. 

We prefer the denomination of tubercular pneumonia, applied by Dr. C, to 
the disease of the lungs known as tubercular phthisis, consumption of the lungs, 
pulmonary tuberculosis, etc., inasmuch as it more clearly expresses the true 
character of the affection, which is, in fact, pneumonia modified in its pheno- 
mena and progress by its occurrence in subjects labouring under pulmonary 
tuberculosis. It is very certain that tubercles may exist in the lungs for a long 
time without the occurrence of inflammation, and without undergoing the process 
of softening. 

"We usually find consumptive patients refer the commencement of the dis- 
ease to some definite period when they have suffered from some unusual expo- 
sure, or when, as they term it, they have taken cold. Perhaps they are more 
correct than is generally imagined. When tubercles exist in the lungs, any of 
the ordinary causes of pneumonia are sufficient to excite inflammatory action. 
We have no proof that tubercles produce inflammation in the lungs ; but when 
inflammation is excited by other causes, they aggravate the difficulty, and in- 
crease the danger, in the same manner that meningitis, in children, is rendered 
more dangerous and fatal by the existence of tubercular deposits. The presence 
of tubercles may be properly considered as constituting a predisposition, and 
then slight causes, which would not be injurious were the lungs in a healthy 
condition, may be sufficient to excite disease." • 

It is, we are persuaded, by the study of pulmonary consumption in this light, 
that satisfactory results can alone be arrived at, in reference to its prophylaxis 
and proper treatment. 

" The history of phthisis is sufficient to demonstrate the importance of a 
correct diagnosis of tuberculosis of the lungs. We find not only many differ- 
ent affections have been confounded under the general name of consumption, but 
that many of the ablest writers have differed as to what actual pathological 
conditions should be embraced under this general term. The term phthisis 
pulmonalis signifies simply a general wasting and exhaustion, consequent on 
pulmonary disease, and may embrace chronic bronchitis, chronic pneumonia, 



1856.] 



Proceedings of American Medical Societies. 



187 



or pleuritic effusions, as well as pulmo-tuberculosis. In point of fact, the two 
first are almost invariable concomitants of the latter when it proceeds to a fatal 
termination, and even pleuritic effusions are not unfrequent in the advanced stage 
of pulmo-tuberculosis. The danger from these different affections is very much 
increased from their connection with tuberculosis. To distinguish tuberculosis 
from other affections, and to determine how much is to be attributed to the one, 
and how much to the other — to be able to say whether the disease is simply 
chronic bronchitis, which has so often been mistaken for pulmo-tuberculosis — 
whether it is simply condensation of the lungs in consequence of congestion 
or inflammation — whether it is suppuration as a consequence of simple inflam- 
mation — whether there is pleuritic effusion, and, if so, whether it is the conse- 
quence of simple pleuritic inflammation, or complicated with diseased structure 
of the lungs, are questions of vital importance in forming a diagnosis and prog- 
nosis in this disease. It is, however, sufficient for all practical purposes to 
divide it into three stages ; the first, embracing the period of simple tubercu- 
losis, without any evidence of inflammatory action ; the second, after inflamma- 
tion has supervened — as true tubercular pneumonia ; and the third, after soft- 
ening and suppuration have taken place, with expectoration of purulent and 
tuberculous matter." 

Of the several signs or symptoms by which the diagnosis of these different 
conditions is to be determined — the physical and the rational, Dr. C. has pre- 
sented a concise, but clear and instructive outline. 

The sketch of the treatment demanded, as well for the arrest of the tubercu- 
lous dyscrasy of the pulmonary tissues, as for the cure of the inflammation oc- 
curring in lungs affected with tuberculosis, presented by Dr. C, is based exclu- 
sively upon the results of his own personal experience. The treatment laid 
down by him is, we are convinced, rational and judicious. It corresponds, in 
its general outlines, with the plan we have ourselves pursued for many years, 
and with such results as justify our unshaken confidence in it. If we hope to 
lessen the mortality — alleviate the sufferings, or prolong the lives of our con- 
sumptive patients, it must be by a careful study of the pathology of the disease 
so as to acquire correct views as to its character and causes, and by a system of 
treatment based upon the teachings of general therapeutics, with an entire 
abandonment of all reputed specifics, and of all plans of medication founded 
in a gross misconception of the morbid conditions it is our duty to remove. 

The third article is a report, by Dr. Thomas W. Blachford, on rest, and the 
abolition of pain in the treatment of disease, 

The importance of rest in the treatment of all acute diseases, has long been 
recognized by every observing and skilful physician, and strongly enforced in 
the leading medical works of a recent date. In the various acute affections of 
the head, thorax, abdomen, pelvis and limbs, and in nearly all fever, our reme- 
dial measures must be aided by perfect rest, or we shall fail in procuring from 
them their desired results. The same holds also in respect to dysentery, diar- 
rhoea, hemorrhage, and many other diseases. It is true, as is properly re- 
marked by Dr. Blachford, that there are a numerous class of ailments, having 
their origin in long-continued sedentary habits, confinement within doors, and 
deficient or unnutritious food, in which regular out-door exercise, active or pas- 
sive, according to the condition of the patient, and graduated in its kind and 
extent by his capability of undergoing it, constitutes an important therapeuti- 
cal agent, without which a cure can scarcely be anticipated. 

To abolish pain is one of the important missions of the healing art. It in 
many cases can be accomplished only by the cure of the disease by which it is 
produced, and with which it is as intimately connected as the effect with its 
cause ; so long as the latter exists must the former continue. Pain is not always, 
however, to be abjured. In many affections, especially those of internal parts, 
it is the voice of nature's sentinel, disclosing the condition within, and could 
we succeed in abolishing it, we should place ourselves in the condition of one 
in a labyrinth, extinguishing his lights that he may grope his way in the dark. 
If, however, the physician may not always aim at the sole object of abolishing 
pain, it is his duty always to use every proper means for its abatement. This 
he often affects by placing his patient or the organ chiefly affected in a state of 



188 



Bibliographical Notices. 



[July 



perfect rest ; by encouraging, by prudent and admissible means, sleep at proper 
intervals, and, generally, by the employment of the remedies adapted to remove 
the pathological condition of which the pain is a consequence. In very many 
cases he has it in his power to alleviate pain by the opportune and judicious 
employment of opiates, narcotics, or other anaesthetic agents internally, or 
locally to the external parts which are the seat of pain. 

The entire subject of rest, and the abolition of pain in the treatment of dis- 
ease is one of great importance. The report of Dr. Blachford presents a series 
of interesting hints in reference to it. The subject is not, however, discussed 
as fully and satisfactorily as we should have desired. 

The fourth article is on the treatment of pneumonia, by Dr. Saunders. This 
is a very short paper. Dr. S. has seen but three cases of the disease during the 
last two years, which, in his judgment, were of so grave a character as to 
require bleeding. 

" My usual treatment," he reports, "is solution of tart. ant. et potass., with 
some form of anodyne, in mucilage and sugar. I as often use the tinct. of 
opii and camphor, with antimony, as any other preparation for adults, and the 
ext. belladonna for children, combining them in sufficient quantity merely to 
allay irritation. I scarcely have a severe case of this disease, and were it not 
for the opportunity I have of knowing cases treated hornceopathically, I should 
be inclined to think that the severe cases did not belong, as a general thing, to 
the region in which I live. I occasionally use calomel, and sometimes blisters, 
with apparent good effect." 

The fifth article is on malignant pustule, and scrofulous gangrene, by Dr. 
Howard Townsend, of Albany. Two cases of what the writer denominates 
scrofulous gangrene, are detailed. They both occurred in children, females, 
both under three years of age ; inmates of the Orphan Asylum of Albany. The 
first case strongly resembled gangrenopsis : in the second, the disease, in place 
of being located in the centre of the cheek, was at the outer angle of the left 
eyebrow. It commenced with a red pimple, from which was developed an 
ulcer of a dusky, almost purplish red hue, with a dry, hard, gangrenous spot in 
the centre ; with thirst, loss of appetite, diarrhoea, and fever ; but without any 
gangrenous affection of the gums or mouth. Both cases terminated fatally. 
This disease seems to Dr. T. to be a peculiar form of inflammation and ulcera- 
tion, superinduced by the strumous diathesis of the patient, and which could 
scarcely be developed in an individual of full, robust health, and free from all 
scrofulous taint. 

The sixth article is the history of fcetation, from coition to parturition, by 
Dr. Thomas Goodsell. The paper is an interesting one — conjectural, as must 
necessarily be the case, in treating of a vital process, or series of vital pro- 
cesses, from the careful observation of which we are completely shut out. We 
cannot spare sufficient space on the present occasion to present an analysis of 
it, and feel no inclination to attempt a criticism of the views advanced by the 
author. 

The seventh article is an able account of encysted osseous tumours, or those 
consisting of a thin secreting membranous cyst, developed in a cancellous 
structure, and surrounded by a thin bony wall ; by Dr. Alden March. This, 
like all the contributions of Dr. March, is of a strictly practical character. The 
account he presents of the peculiar and rather unfrequent form of disease 
which is the subject of the paper, is from personal observation, and the writ- 
ings of Baron Dupuytren. It will be read by the surgeon with equal interest 
and profit. 

A short paper by Dr. J. L. Phelps, follows, intended to show that the mode 
of reducing dislocations of the femur backwards and upwards on the dorsum 
of the ilium, by a peculiar movement of the limb, which has recently attracted 
attention in consequence of the paper read by Dr. Reid, of Rochester, at the 
session of 1852, and subsequently claimed as having originated with Dr. 
Nathan Smith, who demonstrated it before the class in Yale College, in the 
course of 1815-16, was performed by Dr. Physick as early as January, 1811, 
in the Pennsylvania Hospital. 

The ninth paper is the history of a case of chronic nephritis, resulting in dis- 



1856.] 



American Insane Hospital Reports. 



189 



organization and entire absorption of the substance of the left kidney, commu- 
nicated by Dr. Gr. J. Fisher, of Westchester County. Few details could be col- 
lected of the previous history of the case of a satisfactory character. In the 
place of the left kidney was a sac filled with fluid, slightly turbid, resembling 
urine that had been voided several hours. The sac was of the same general 
outlines as, but much larger than, the kidney, with a cord extending from it 
to the bladder, being the obliterated ureter. The right kidney was slightly 
softened. The liver and spleen hypertrophied and enlarged. The patient was 
a convict, of intemperate habits, 56 years of age. He was subject to frequent 
attacks of pain in the lumbar region ; his extremities were ©edematous ; and he 
had for years been affected with a degree of nervousness, which, for some time 
previous to his death, amounted to complete chorea. 

The closing article is a biographical sketch of Dr. Thomas Brodhead, an old 
and respectable physician of Columbia County, Y., communicated by Dr. 
P. Van Buren. 

5. Pursuant to an invitation addressed to the members of the medical pro- 
fession throughout the State of California, a convention, composed of a numer- 
ous delegation from the various sections of that commonwealth, assembled in 
Sacramento City, on the 12th of March, 1856, and organized the State Medical 
Society of California, with auxiliary societies in each town or county. The 
proceedings of that convention and of the first meeting of the State Society are 
before us. They show that a right spirit animates the body of the profession 
there, to secure to themselves an entire cooperation, and the cultivation of that 
friendly intercourse which should ever be manifested between those engaged in 
common pursuits having for their objects the alleviation of suffering, the de- 
velopment of the physical energies, and the prolongation of the lives of their 
fellow men — laying thus the foundation upon which must be based, in the first 
instance, the means for the amelioration of the condition of every community, and 
their advance in civilization, refinement and happiness. Without which co- 
operation and fraternal feeling the proper standing, and the true and legiti- 
mate interests of the medical profession can never be attained, while its indi- 
vidual members, isolated from each other, and regardless of the rights and 
interests of other physicians — striving to promote their own popularity and 
pecuniary success without reference to what is due, in an ethical point of view, 
to their fellow practitioners, bring themselves into merited contempt, and lower 
the entire profession in the estimation of the public. The physicians of Cali- 
fornia have taken the proper steps, and in a proper direction, to advance their 
common good, and to place themselves, as a body, in their true position in so- 
ciety ; and at the same time, by a combined effort, each member within his field 
of observation, doing his share of the work, to present, in the investigation of 
the etiology, character, progress, treatment, and results of the endemic and 
epidemic maladies of California, a valuable contribution to the common stock 
of medical knowledge. D. F. C. 



Art. XIY. — Reports of American Institutions for the Insane. 
X. Of the Maine Insane Hospital, for the years 1854 and 1855. 

2. Of the New Hampshire Asylum for the Insane, for the years 1854 and 1855. 

3. Of the Vermont Asylum for the Insane, for the years 1854 and 1855. 

4. Of the Massachusetts Lunatic Hospital, Worcester, for the years 1854 and 

1855. 

5. Of the Boston Lunatic Asylum, for the year 1852. 

6. Of the New York City Lunatic Asylum, for the years 1854 and 1855. 

7. .Of the Maryland Hospital for the Insane, for the years 1853, 1854, and 1855. 

8. Of the Mount Hope Institution, for the years 1854 and 1855. 

9. Of the Western Lunatic Asylum, Virginia, for the years 1854 and 1855. 
10. Of the South Carolina Lunatic Asylum, for the years 1853 and 1855. 

1. By the report of Dr. Harlow, of the Maine, State Asylum, it appears that 
the number of patients at that institution, on the 30th of Nov. 1853, 
No. LXI1L— July 1856. 13 



190 



Bibliographical Notices. 



[July 



Men. 



Women. 



Total. 



Was 



61 
57 
118 
56 
62 
26 
16 



58 
53 
111 

58 
53 
23 
16 



119 
110 
229 
114 
115 
49 
32 



Admitted in course of the year 
Whole number .... 
Discharged, including deaths 
Remaining Nov. 30, 1854 
Of those discharged, there were cured 



Died 



Causes of Death. — Dysentery 16; general paralysis 5 ; consumption 2; old age 
2 ; marasmus 2 ; serous apoplexy 1 ; congestion of brain 1 ; typhoid fever 1 ; gan- 
grene 1 ; epilepsy 1. 

" About the first of August," says the report, " an epidemic diarrhceal dysen- 
tery broke out in our wards, and for three months little else than the sick and 
dying occupied our attention. There was scarcely an individual connected 
with the hospital family who escaped the ravages of the disease. Officers, 
attendants, nurses and assistants shared alike with the patients in the attack. 
Just in the midst of the epidemic, when it would seem the services of the 
superintendent and steward were most needed, we were prostrated and unable 
to perform our duties. Having no medical assistant, we were obliged to call 
in a neighboring physician to attend the patients. Fortunately, the trustees 
were able to procure the valuable services of Ex-Governor Hubbard, who was 
formerly, for several years, a member of their board, and who has always felt 
and taken a deep interest in the hospital. He visited us daily for four weeks, 
and attended upon all the sick in the house till we were able to attend to our 
duties." Of ninety persons attacked by this epidemic, seventeen, of whom 
sixteen were patients, and one a female attendant, died. 

The number of patients admitted, since the first opening of the hospital for 
their reception, is 1430. Discharged, 1316, of whom 590 had recovered. Died 



To avoid the labour and the inconveniences attendant upon the return of 
patients who, on the supposition of recovery, have left the hospital with the 
formalities of a regular discharge, but who, after a few days, either suffer a 
relapse or give evidence of imperfect restoration, Dr. Harlow has adopted the 
plan pursued at some of the European hospitals, of discharging all in regard 
to whom he has "doubts of their fitness, on trial, for a period of two weeks." 

Of 1200 patients who have been in the hospital, 586 had insane relatives. It 
is not stated whether these 1200 were so many persons, or merely so many 
cases, including a considerable number of re-admissions of the same person — 
conditions which materially affect the percentage. 

In some remarks upon the deleterious effects of a forced, early intellectual 
education, Dr. H. remarks that he " was most forcibly struck, in reading an 
account of a class of students who graduated at one of our New England Col- 
leges, in 1827. It was found that of this class, numbering twenty-three, all 
but two had survived the lapse of quarter of a century; and it was also found 
that nearly every member of the class had arrived at adult age before entering 
college, thus escaping that premature excitement and development of the intel- 
lect which paves the way to mental disease, and furnishes tenants for many an 
early grave." 

At the date of this report an additional wing for females was in course of 
construction. 

In the report for 1855, we are informed that the new wing is completed, and 
occupied. The original design is thus finished, and the hospital can now ac- 
commodate two hundred and fifty patients. 



175. 



Patients in the Hospital, Nov. 30, 1854 
Admitted in course of the year 
Whole number .... 



Men. 
64 
66 

130 




Total. 
115 1 
128 
243 



1 The number assigned to each sex, does not correspond with that of the report of 
the preceding year. 



1856.] 



American Insane Hospital Reports. 



191 



Men. Women. Total. 

Discharged, including deaths ... 44 44 88 

Remaining, November 30, 1855 86 69 155 

Of those discharged, there were cured . 41 

Died ....... 19 

Deaths from general paralysis 5, epilepsy 3, chronic diarrhoea 3, tubercular 
consumption 2, congestion of the brain 3, old age, nephritis, and typhoid fever, 
1 each. 

" The propensity," says Dr. Harlow, " that exists in the minds of many of 
the friends of our patients, to remove them from the hospital too soon after 
they have been admitted, continues to be an evil which we should be glad to 
see eradicated. We are happy to say, however, that the evil appears to be 
growing less from year to year." 

Patients admitted since the hospital was opened . . . 1559 

Discharged recovered 631 

Died 193 

"Owing to the two epidemics, and the great calamity by fire, with which 
the hospital has been visited since its existence, the bill of mortality is larger 
than (that of) some similar institutions." 

Basing his calculation upon the results obtained by the commission which 
took the census of the insane and the idiots in Massachusetts, in 1854, Dr. 
Harlow concludes that, in Maine, there are 1365 lunatics and 560 idiots. 
"The question arises," he remarks, "where are all these 1365 lunatics, and 
what is their condition ? Some are cared for at home, by their friends, either 
chained or caged, if unmanageable, and some 150 are in the hospital, while by 
far the largest proportion of them are at the various Almshouses in the State, 
many of them caged and chained, because they can be kept a few cents less 
per week than it costs at the hospital." Where is that other "Maine Law ?" 

2. At the New Hampshire Asylum for the Insane, on the 31st of May, 1853, 
the number of 

Patients was . . . . 
Admitted in the course of the year 
Whole number .... 
Discharged, including deaths 
Remaining May 31st, 1854 
Of those discharged, there were cured 
Died 

" During the whole year our household has enjoyed remarkable physical 
health. We have been entirely exempt from epidemics of all sorts, and acute 
disease has been almost unknown. Cleanliness, regularity of life, and a most 
healthful location have been the chief causes of this desirable state of things. 
The deaths which have occurred, with a single exception, were of those who 
for a long time were considered incurably insane, and who at last were lite- 
rally worn out by the continued and unremitting force of their malady. 

" Through the whole year our female halls have been full, and often crowded, 
and our male halls at all times crowded." This condition " prevents a proper 
classification of patients, and seriously interferes with all curative measures." 
Dr. Tyler therefore recommends that an additional wing be erected. 

"We can in almost no case infallibly pronounce a person incurably insane ; 
certainly the records of the asylum for the year show the recovery of some 
whose improvement seemed impossible, and whose present condition, among 
their friends and in perfect health and soundness of mind, seems a miracle." 

" The house is now lighted with gas, and we not only find its use more con- 



Men. 


Women. 


Total. 


70 


73 


143 


72 


69 


141 


142 


142 


284 


67 


56 l 


123 


77 


84 


161 


34 


29 


63 


7 


•7 * ' 


14 



1 These numbers are quoted from the report. But if 67 men and 56 women were 
discharged, the number remaining would be 75 and 86, instead of 77 and 84. 



192 Bibliographical Notices. [July 

venient, comfortable and cleanly than oil, but its brilliant light a curative 
means, in making our previously half-lighted halls cheerful and pleasant/ 7 
Report for 1855. 

Men. Women. Total. 
Patients on the 31st of May, 1854 77 84 161 

Admitted in course of the year ... 45 40 85 

Whole number . 122 124 246 

Discharged, including deaths ... 50 41 91 

Remaining May 31, 1855 .... 72 83 155 



Among the patients who were discharged recovered, Dr. Tyler says there 
was " a man of intelligence and education who was for nearly eleven^years an 
inmate of this institution." 

The asylum is rapidly becoming filled with incurables. But about one-half 
of the applicants for admission can be received. The Doctor recommends that 
an additional wing be erected. A building for the violent patients is in pro- 
gress. 

From the answers to circulars sent to every city and town in New Hamp- 
shire, and from other sources, Dr. Tyler ascertains that there are 35 insane 
persons belonging to the State who " are supported by their friends or guar- 
dians in hospitals in other States ; and that there are now resident in the 
State more than 550 insane persons, only 155 of whom are in this asylum. Of 
the remainder, many are kindly and comfortably taken care of at home, or 
with friends, or at almshouses ; but others are chained, and caged, and sadly 
neglected ; in filth, and exposure to the inclemencies of the weather. Some 
instances of cruelty and neglect have lately come to our knowledge, that, if 
known, would startle the neighbourhoods in which they have occurred." 



Whole number of patients from the opening of the Asylum . 1284 

Discharged cured 547 

Died ........... 118 

3. At the Vermont Asylum for the Insane, on the 1st of August, 1853, the 
number of 

Men. Women. Total. 

Patients was 183 189 372 

Admitted in course of the year ... 77 86 163 

Whole number . . . . . .260 275 535 

Discharged, including deaths ... 72 74 146 

Of whom there were recovered ... 80 

Died ........ 40 



It appears that a large number of the patients at this Asylum are employed 
on the farm, in the garden, and in the workshop. Dr. Rockwell also encou- 
rages them to join in "all amusements which require exercise of the body as 
well as diversion of the mind, and especially riding, walking, playing billiards, 
ten-pins, quoits, and the like." He would " rather they would play chess, 
draughts, cards, and such like games than do nothing." 



Men. W'omen. Total. 

Patients, August 1st, 1854 . . . 188 201 389 

Admitted in course of the year . 78 86 164 

Whole number . ^ ..... 266 287 553 

Discharged, including deaths . . . 159 

Remaining, August 1st, 1855 . . 394 

Of those discharged, there were recovered 79 

Died 52 

Whole number of patients since the open- 
ing of the Asylum 2393 
Discharged, recovered . . . .. . 1127 



1856.] 



American Insane Hospital Reports. 



193 



The unusually large number of deaths during the last year, is accounted for, 
in part, by the prevalence of a severe and fatal form of dysentery which ap- 
peared among the patients in the early part of summer, and continued with 
unabated severity throughout that season. The number of attacks is not men- 
tioned, neither is that of the cases in which it proved fatal. Warned by the 
two epidemics which have been mentioned, the directing authorities of the in- 
stitution have ordered the construction of two infirmaries, one for either sex, 
wherewith, in the event of a future similar invasion of disease, the invalid 
patients can be isolated from the others. These apartments have been com- 
menced. 



Men. 


Women. 


Total. 


266 


254 


520 


125 


174 


299 


391 


428 


819 


198 


240 


438 


193 


188 


381 


45 


77 


122 


15 


19 


34 



4. The State Lunatic Hospital of Massachusetts, at Worcester, has for se- 
veral years been greatly, almost unjustifiably crowded with inmates. It, its 
officers, and its patients have at length obtained some relief. The inconve- 
nient and unwholesome condition of things has been changed for the better. 
Another State Hospital has been erected at Taunton. To this, on the seventh 
of April, 1854, "and on each of the five succeeding Fridays, a car load of pa- 
tients" were transferred from the hospital at Worcester. The number thus 
removed was 210. No accident occurred in this rarely-paralleled migration. 
" The patients were mostly of a very orderly class, and they were gratified with 
the ride." Notwithstanding this great abstraction from its wards, the hospital 
was left "quite full, but not crowded," and it became possible to abandon the 
use of a number of cells and improperly-contrived rooms which had long been 
tenanted by patients. 

Patients in the Hospital, Dec. 1, 1853 
Admitted in course of the year . 

Whole number 

Discharged, including deaths 
Remaining Nov. 30, 1854 . 
Of those discharged, there were cured 
Died . . . . 

Causes of Death. — Marasmus 5; consumption 4; lung fever 4; maniacal ex- 
haustion 7 ; apoplexy and palsy 3 ; epilepsy 2 ; erysipelas 2 ; suicide, dropsy, 
chronic dysentery, diarrhoea, congestive fever, asthma, and jaundice, 1 each. 

In connection with the causes of insanity, Dr. Chandler makes the following 
remarks: "Probably in no part of the world are the causes of insanity more 
numerous and more active than among the population of Massachusetts. Here 
the mind, and body too, are often worked to the extreme point of endurance. 
Here wealth and station are the results of well directed efforts ; and the general 
diffusion of intelligence among the people stimulates a vast many of them to 
compete successfully for these prizes. But in the contest, where so many 
strive, not a few break down. The results on their minds may not, perhaps, 
be any less disastrous, whether wealth and station are obtained, or not. The 
true balance of the mind is disturbed by prosperity as well as by adversity. 
It is only in a sound body that the manifestations of the mind are sane and 
entirely healthy. As a people, we cannot boast of the highest standard of 
physical health, although we may of general intelligence, enterprise, and hard 
work." 

In the course of the year 1855, very important improvements were made in 
this establishment. Not the least of these was the introduction of the appa- 
ratus for heating by steam, and that for ventilating by mechanical power. 
Relieved, by the hospital at Taunton, of its great excess of patients, and 
brought, by improvements, more nearly into conformity with the idea of the 
times, this institution may still, for a long number of years, continue its career 
of usefulness. Indeed, it seems that Dr. Chandler is unwilling to acknowledge 
that it has ever merited the impression which has been made upon the public 
mind in regard to it. "Whatever," he remarks, " may have been said against 
this hospital — and most of what has been said about its defects, has been so 
said as an excuse to make it still better — it has always afforded, and does now, 



194 



Bibliographical Notices. 



[July 



with all the progress made in others, a residence as comfortable and as cheer- 
ing, and as healthful to the patient, as any similar institution in this country." 

In this expression we believe Dr. C. is mainly correct. The only exception 
suggested relates to the hygienic condition of the building. It can hardly be 
assumed that, with its comparatively low ceilings, and its imperfect ventila- 
tion, it can be so healthful, other things being equal, as some of the similar 
edifices more recently erected. For the impression which has gone abroad in 
regard to it, the Board of Trustees who have the control of it are chiefly re- 
sponsible. They drew the picture of its defects ; and if their painted grapes 
bear such a semblance to reality that the birds have pecked at them, truly it is 
not the birds that should bear the blame. All who have visited the hospital 
are well aware that the picture was a sketch of the shady side alone, and that 
another, drawn from the sunny side, might be made as attractive as the first 
was repulsive. 

From its earliest years we have been a not unfrequent visitor to this hospital, 
and in this place we feel bound to acknowledge our belief that, from its origin, 
it has been not only well, but very well managed. We would shun invidious 
distinctions — we shall make none; yet justice demands from us the expression, 
that there is no institution in the country at which we could, at any time, have 
placed a friend with greater confidence that all his necessities would be sup- 
plied ; that his comforts would be carefully ministered to; that he would be 
shielded from abuse ; and that his restoration would be wrought for with 
watchful care, with constant assiduity, and with that skill which is the result 
of a good professional knowledge, combined with practical experience. 

" We avail ourselves of this occasion," write the trustees, in their report, 
" to bear testimony to the fidelity and signal ability with which Dr. Chandler 
has discharged the duties of his position, and to the great success which has 
attended his labours during the whole period of his superintendence." 

Dr. Chandler has resigned his office, and Dr. Merrick Bemis, for some years 
one of the assistant physicians of the hospital, has been appointed as his suc- 
cessor : — 

Patients in the hospital Dec. 1, 1854 
Admitted in the course of the year . 
Whole number admitted in the course 

the year 

Discharged, including deaths 
Remaining, Nov. 30, 1855 
Of those discharged, there were cured 

Died 

Admitted from Jan. 18, 1833, to Nov 

1855 . . . . .. 

Discharged, recovered 
Died ... 

Of this aggregate number of deaths, 87 are attributed to marasmus ; to 
"consumption 67; apoplexy and palsy 59; maniacal exhaustion 59; epilepsy 
50; suicide 22; lung fever 22; disease of the brain 21; disease of the heart 
20 ; diarrhoea 19 ; erysipelas 17 ; old age 14 ; typhus fever 11 ; dysenteric fever 
10; dropsy 10; inflammation of the bowels 8 ; hemorrhage 6; cholera mor- 
bus 5; chronic dysentery 5 ; gastric fever 5 ; cholera 4; mortification of the 
limbs 3 ; from intemperance 3 ; bronchitis 3 ; congestive fever 3 ; hydrotho- 
rax 3 ; convulsions 2 ; asthma 2 ; disease of the bladder 2 ; cancer 2 ; jaundice 
2 ; land scurvy 1 ; concussion of the brain 1 ; fright 1 ; rupture 1 ; pleurisy 1 ; 
chorea 1." 

In reference to the salubrity of the hospital, this schedule of the mortality 
among almost five thousand patients, in the course of a period but little less 
than twenty-three years, is well worthy of a careful perusal. Its testimony is 
more reliable than that of individual opinion ; more forcible than arguments 
deduced from theories of architectural construction. The almost entire ex- 





Men. 


Women. 


Total. 




193 


188 


381 




86 


113 


199 


of 










279 


301 


580 




111 


133 


244 




168 


168 


336 




50 


59 


109 




13 


14 


27 


30', 








2,451 


2,505 


4,956 




1,089 


1,195 


2,284 




281 


272 


553 



1856.] 



American Insane Hospital Reports. 



195 



eraption from fatal epidemics, from severe endemic fevers, and from other acute 
diseases, to which it bears record, -will find but few parallels in any other in- 
stitution of the kind in any quarter of the globe. 

Under the table of causes we find the following remarks : — 
" Spiritualism of the present day is of the last (moral) class of causes. This 
singular mental phenomenon has, for some years, engaged a part of the minds 
in this vicinity, and some few cases have been brought to us the past, as well 
as previous years, arising, it was supposed, from investigating its phenomena, 
and from believing in its supposed truthful revelations of the future state of 
existence. If it was true that this process of investigation did really open to 
the mind any knowledge of the world to come, not revealed to us by the 
Scriptures — which many of its votaries assert and believe — then it would be a 
cause calculated in the highest degree to engage, excite, and disturb the mind. 
But it has been said by those best prepared to investigate closely, that the re- 
sponses through the mediums contain no ideas of this or the next world, that 
were not then, or had not previously been, in the mind of some one present. 
It may be a new faculty of the mind, but its field of operation lies this side of 
the grave." 

In regard to moral treatment, Dr. Chandler writes as follows : " We recog- 
nize the principle of giving the largest liberty, and the greatest freedom from 
restraint, in each case, consistent with the security of the individual and safety 
of the community. * * * About one-half of our patients perform some 
kind of labour, more or less useful. For plain work, the patients are ready 
and very efficient. One day this autumn the patients, with one hired man, 
dug, took off the tops, and put into the cart, four hundred and eighty bushels 
of carrots. Some are ingenious mechanics. Two have assisted the carpenters 
most of the season. One gentleman has made all the soft soap — three hundred 
and fifty barrels a year — and some of the bar soap, for five or six years. He 
has gathered the materials, made and distributed, and attended to the econo- 
mical use of it. No one can make better soap than he. Two have made oar 
baskets for years, and have supplied themselves, in part, with clothing. One 
female has made pantaloons and vests to supply the demand in our family. 
The females make the shirts, and knit the stockings; they wash and mend; 
they cook, and they help about all our domestic affairs. * * * Whip-lash 
braiding * * * is the best employment I can think of to introduce among our 
patients in-doors." 

5. The report for the fiscal year ending with the month of November, 1852, 
is the latest which we have seen from the Boston Lunatic Asylum : — 



Men. 


Women. 


Total. 


100 


141 


241 


41 


11 


52 


141 


152 


293 


34 


15 


49 


107 


137 


244 


17 


5 


22 


14 


8 


22 



Patients at the beginning of the year 
Admitted in course of the year 

Whole number 

Discharged, including deaths 
Remaining at end of year 
Of those discharged, were cured 
Pied . , " , , . 

Causes of Death. — Consumption 8; debility 3 ; general paralysis 3; epilepsy 
2 ; chronic mania 2 ; smallpox 1 ; " Asiatic diarrhoea" 1 ; old age 1 ; maras- 
mus 1. 

" It is a noticeable fact," writes Dr. Walker, " that no death from dysentery 
has occurred. This disease has prevailed extensively among us for several 
successive years, always bringing with it great suffering, and ceaseless anxiety. 
Early in August it appeared in a very violent form, bringing several of our 
household rapidly to the verge of the grave. Fires were immediately lighted 
in the furnaces morning and evening, so that when the patients were rising 
and retiring, a current of warm air should be passing through the halls and 
bedrooms. * * * The most unpromising cases speedily began to amend, and 



196 



Bibliographical Notices. 



[July 



Men. 


Women. 


Total. 


232 


310 


542 


224 


262 


486 


456 


572 


1,028 


211 


262 


473 


245 


310 


555 






186 






190 



at the time when the disease usually raged the most fiercely, not a case was 
under treatment." 

The report for 1851 from this institution, contained a brief but interesting 
account of the case of an Irish boy, among the patients. This account was in 
whole or in part transferred to our notices. The report before us states that 
the boy has left the institution " giving promise of future usefulness." 

6. New York City Lunatic Asylum, on Blackwell's Island. 

Number of patients on the 1st of January, 

1854 

Admitted in course of the year 

Whole number 

Discharged, including deaths 
Remaining, Dec. 31, 1854 
Of those discharged, there were cured 
Died 

Among the cases cured, there were four of delirium tremens. Of the cases 
admitted, nine were improper subjects for the institution. 

Causes of Death. — Cholera 83 ; consumption 34; paralysie g6nerale 19 ; ty- 
phomania 9 ; " debilitas" 9 ; epilepsy 8; congestion of brain 7 ; dysentery 3 ; 
chronic diarrhoea 3 ; old age 2 ; typhus fever, pneumonia, erysipelas, hydro- 
cephalus, albuminuria, suicide by suspension, injuries of head, injuries from 
fall, "submersion," peritonitis, gastroscirrhus, pericarditis, ascites, 1 each. 

Dr. Ranney gives the following account of the cholera, by which, as will 
have been perceived, nearly one-half of the mortality was occasioned: — 

"The epidemic commenced on the 22d of July, and terminated on the 22d of 
August. An attendant, however, was attacked on the 11th of September, and 
died in twelve hours. Four of the other attendants had cholera of a severe 
form, but all recovered. It seemed more violent, and proved more fatal than in 
1849, and nearly the same class was affected, viz: those in whom the consti- 
tution was greatly impaired from chronic disease, and the mind reduced to the 
most hopeless state. Frequently, the first warning was complete collapse, 
characterized by blueness of the skin, coldness of the surface, and loss of 
pulse. Cramps were less common than in 1849. If diarrhoea occurred, as a 
premonitory symptom, it was readily checked by medicine." 

" Chronic diarrhoea has become much less frequently a cause (of death) since 
the introduction of Croton water on the island." 

Of the 486 patients admitted in the course of the year, only 97 were natives 
of the United States. Of the foreigners, 241 were from Ireland ; 91 from Ger- 
many; 21 from England; and 9 from Scotland. The remainder were from 
various countries. One hundred were supported by the Commission of Emi- 
gration, and all these were immigrants of the preceding five years. 

" A large proportion of the recent immigrants recover; the derangement of 
mind being generally produced by privations on ship-board, and the changes 
necessarily incident on arriving in a strange land. Their exposures and suffer- 
ings are occasionally very great in crossing the Atlantic, and, in a few, the 
aberration of intellect has seemed to depend entirely on the want of sufficient 
nourishment. A poor German boy was admitted last March, who had just 
arrived in New York. His suffering from starvation had been so great as to 
obliterate from his memory all knowledge of having crossed the ocean, and he 
fancied himself in his father-land ! He would implore me, in the strongest 
terms, to allow him to go on his journey, as in a few hours he would meet his 
father and mother, who were anxiously awaiting his return. Then a change 
would come over him, and he would imagine that he was detained as a culprit. 
He would plead his innocence with feeling eloquence, and in the most melting 
terms. These delusions were so firmly fixed that he would listen to no explana- 
tion, and the only effectual quietus was the liberal and constant supply of 
nutriment. His thirst fully equally his appetite for food. I subsequently 



1856.] 



American Insane Hospital Reports. 



197 



learned that he was a native of the Grand Dukedom of Baden, and that he had 
been seventy days in making the voyage from Bremen to New York. In two 
weeks the delusion disappeared, and he became fully conscious of his condi- 
tion. In two months his mind was perfectly restored, when he left the asylum, 
as noted for excessive fatness as he had previously been for his emaciated and 
meagre appearance." 

We rejoice to learn, as we do from the report for 1855, that one of the foulest 
blots which has rested upon the practical psychiatry of our country, has at 
length been effaced. " The most decided improvement ever made in this asy- 
lum," remarks Dr. Ranney, " has been consummated the past year. I refer to 
the entire removal of prisoners, not only from their immediate connection with 
the insane, but from the institution. 

"From 1826 to 1847, the work of the asylum was performed, and the prin- 
cipal charge of its inmates taken, by persons transferred from the different 
penal institutions on the island. At the commencement of the year last named, 
six of that class were employed in each of the halls, and between fifty and sixty 
engaged as domestics about the building. One-fourth of the whole number at 
the asylum being convicts, the institution differed little, in its morale, from a 
prison. It was urged upon the common council, ' that the same individuals 
who were committed in the city as criminals, and required an armed keeper in 
the penitentiary, were sent here to take charge of a class who require the most 
mild and soothing treatment/ But the memorials sent, soliciting a change in 
the system, produced no effect." 

And be it remembered that no action was taken upon the subject until after 
the asylum had ceased to be one of the footballs of partisan politics, by that 
worthy act of the State Legislature, which wrested the government of the 
Almshouse Department of the City of New York from the municipal authori- 
ties, and vested it in a Board of Governors selected in equal, or nearly equal 
numbers, from the two most prominent political parties of the day. The change 
commenced in 1850, when prisoners were removed from three of the halls for 
patients, and has gradually progressed to its final completion. 



Patients in the asylum Dec. 31, 1854 
Admitted in course of the year 

Whole number 

Discharged, including deaths, . 
Remaining, Dec. 31, 1855 . , 
Of those discharged, there were cured 
Died 



Men. 


Women. 


Total. 


245 


310 


555 


163 


208 


371 


408 


518 


926 


170 


183 


353 


238 


335 


573 






200 






100 



The disease of six patients, recorded among the cured, was delirium tremens. 

Deaths from consumption 29 ; paralysie generale 18 ; epilepsy 7 ; chronic 
diarrhoea 7 ; typhomania 6 ; old age 5 ; congestion of brain 5 ; hemiplegia 3 ; 
anasarca 3 ; inflammation of brain 2 ; apoplexy 2 ; typhus fever 2 ; hypertrophy 
of heart 2 ; pneumonia 2 ; bronchitis, pleurisy, hydrothorax, ascites, erysipelas, 
scorbutus, and accidental drowning, 1 each. 

• So long as the circumstances controlling the population of this institution 
shall continue such as they are at the present time, so long must its annual 
records present a large bill of mortality. It is, in fact, the receptacle of the 
offscourings of the civilized world. Of the 371 patients received in 1855, only 
78 were natives of the United States, while 293 were foreigners. Of the latter, 
288 were Europeans. Ireland was represented by 178 ; the German states, in- 
cluding Austria and Prussia, by 68 ; England by 19, and eight of the other 
nations by smaller numbers. Some of these came with broken constitutions, 
many of them under the depressing influence of disappointed hopes, many with 
the typhoid effects of the voyage by sea still upon them, and some labouring 
under a combination of two or more of these vultures to vitality. There are 
also other causes, perhaps of minor importance, but still of sufficient magni- 
tude to swell the sum of forces tending to a fatal issue. 

The moral treatment at this institution is gradually becoming broader, more 



198 



Bibliographical Notices. 



[July 



systematic, and more effective. Musical concerts, or parties, have been held 
from two to three times in each week. " New Year's day, the Fourth of July, 
Thanksgiving, and Christmas were appropriately observed. The oration de- 
livered by one of the inmates, on the Fourth, is a creditable production. The 
reading of the Declaration of Independence, the music, and the original ode, 
would compare favourably with the usual ceremonies on similar occasions. 
About three hundred and fifty patients joined in the celebration. 

" One of the most pleasant and interesting of our amusements has been the 
holding of ' Moot Courts.' Many could directly participate in these, either as 
plaintiff, defendant, counsel, judge, or juryman. The minor offences alone 
were tried by this supreme court of Black well's Island. The judge, noted for 
benevolence and wealth, and preferring to pay the damages rather than have 
any one suffer from the uncertainty of the law, gave decisions — unlike those of 
the city courts — satisfactory to both parties." 

7. The reports by Dr. Fonerden, of the Maryland Hospital for the Insane, are 
very brief, limited almost exclusively to a short account of the changes in the 
patients resident, and to such subjects appertaining to the management of the 
hospital as are of merely local interest. The statistics of those now under 
review, are condensed into the subjoined table: — 







1S53 






1S54 






1855 




AGGREGATE. 




M. 


W. 


Tot. 


M. 


* 


Tot, 


M. 


W. 


Tot. 


% 


W. Tot. 


Patients on the 1st of January . 


68 


62 


130 


57 


60 


117 


56 


63 


119 


68 


62 130 


Admitted in course of the year . 


29 


21 


50 


23 


23 


46 


42 


28 


70 


94 


72 166 


Whole number .... 


97 


83 


180 


80 


83 


163 


98 


91 


189 


162 


134 296 


Discharged, including deaths 


40 


23 


63 


24 


20 


44 


39 


29 


68 


103 


72jl75 


Remaining, December 31 . 


57 


60 


117 


56 


63 


119 


59 


62 


121 






Recovered .... 


8 




11 


10 


7 


17 


13 


13 


26 


31 


231 54 


Died ....... 


7 


2 


9 


5 


3 


8 


CO 


4 


17 


25 


9 34 



Previously to the year 1855, some cases of mania a potu were received at 
this institution ; but we are informed by the report for 1850, that such cases 
are not enumerated in the tabular accounts of the insane. 



8. From the report of Dr. Stokes, Physician to the Mount Hope Institution, 
near Baltimore, we extract the subjoined numerical results for 1854: — 

Patients on the 1st of January, 1854 
Admitted in course of the year . 
Whole number in course of the year 
Discharged, including deaths 
Remaining, Jan. 1, 1855 
Of those discharged, there were cured 
Died . 

Causes of Death. — Acute mania 2 ; apoplexy 1 ; Bright's disease 2 ; epileptic 
convulsions 2 ; puerperal mania 2 ; exhaustive mania 3; phthisis 2; "gradual 
senile decline" 1. 

" Erysipelas and dysentery prevailed to a considerable extent during the 
summer, but in no case did they prove fatal. 



Men. 


Women. 


Total. 


45 


87 


132 


54 


51 


105 


98 


139 


237 


41 


48 


89 


56 


91 


147 1 


19 


18 


37 


7 


8 


15 



1 All these figures are given as they are in the report, without an attempt to harmo- 
nize them. Of men, there were 45 at the beginning of the year, and 54 admitted ; yet 
the total is made 98. Of the women, the two items and the aggregate similarly dis- 
agree. It is stated, in general, that 41 males and 48 females were discharged ; yet, 
immediately afterwards, in giving the details of cures, improvement, deaths, &c, the 
number of males is made 42, and that of females 47. 



1855.] 



American Insane Hospital Report i 



199 



" During the entire year the institution has been rather more than com- 
fortably filled." 

From the remarks upon " premature removals," we make the following ex- 
tract: "Those practically familiar with the habitudes of the insane, and the 
motives and influences under which they act, know full well that many, who 
are violent, noisy, and outrageous whilst under the care of their friends, be- 
come calm and docile when subjected to the mild but firm discipline and moral 
treatment of an asylum. Such a change does not indicate a cessation, or even 
(in some instances) the mitigation of disease ; it merely shows that it is held 
under control by the varied influences brought to bear on it. * * * * 
Many of our inmates who are peaceful and contented, cheerfully occupied 
throughout the day, entering with pleasure into the amusements and recrea- 
tions afforded them, or rambling at will in the grounds of the asylum, would 
become unhappy and unmanageable if restored to the exciting cause of their 
malady." 

We proceed to the report for the year 1855 : — 

Patients on the 1st of January . 
Admitted in the course of the year . 
Whole number in the course of the year 
Discharged, including deaths 
Remaining, Jan. 1, 1856 . 
Of those discharged, there were cured 
Died 



Men. 


Women. 


Total. 


56 


91 


147 


49 


46 


95 


105 


137 


242 


59 


61 


120 


46 


76 


122 


19 


7 


26 


7 


7 


14 



Of the patients who were discharged improved, or unimproved, forty-six 
belonged to the District of Columbia, and, being supported by the national 
government, were transferred to the Government Hospital for the Insane, near 
Washington. 

Upon the subject of injudicious visits to patients, by their friends, Dr. Stokes 
says : " It is astonishing with what a reckless and criminal disregard of the 
most earnest representations of the injury likely to be inflicted, this course is 
persisted in. Thus it is that the patients' mental health and future happiness 
are often jeoparded by the indiscreet action of those most interested in their 
recovery. Strange to relate, after informing them that such a step is calculated 
to entail chronic insanity upon the patient for life ; that its certain effect will 
be to protract the disorder, and thus increase and prolong the trouble and ex- 
pense of his maintenance, many instances have occurred during the past year 
wherein they have obstinately persisted in their insane course." 

The following case is related in the observations upon epileptic mania: " In 
a case now under treatment the person, whose attacks seldom amount to 
spasms, or even a distortion of the features, but in whom the loss of concious- 
ness is complete for the time, would really seem to possess two natures. His 
life presents two decidedly distinct phases ; the one embracing a period of a 
week preceding or following the attacks, during which he is suspicious, timid, 
apprehensive of plots to destroy him, malicious and vindictive. He is then 
. irritable and imperious, violent and gloomy. In the other phase, in a manner 
normal, his character manifests itself under an entirely different aspect, ex- 
hibiting the capacities of a man in possession of good sense, and free from all 
extravagance." 

In four cases, the abuse of opiates is alleged as the cause of the mental 
aberration. "Opium," remarks Dr. S., "is much more used by females than 
by males, and there exists abundant proof that the vicious habit of this in- 
dulgence prevails much more extensively than is supposed. From two to four 
ounces of laudanum a day is by no means an unfrequent allowance." 

Among the facilities, and the adopted plans for moral treatment mentioned 
in this report, are books, music, embroidery, excursions, a saddle-pony, musical 
reunions, dancing, books, games, and newspapers. In the report for 1844, it 
is mentioned that the anniversaries of the Fourth of July and Christmas are 
appropriately observed. 



200 



Bibliographical Notices. 



[July 



9. The report by Dr. Stribling, of the Western Lunatic Asylum, Virginia, 
extends over two fiscal years : — 

Patients in the Asylum, Oct. 1, 1853 
Admitted in the course of two years 

Whole number 

Discharged, including deaths 
Kemaining, September 30th, 1855 
Of those discharged, there were cured 

Died 

Whole number of patients admitted from 

July 1, 1836 

Discharged, cured .... 
Died 



Men. 


Women. 


Total. 


217 


160 


377 


90 


63 


153 


307 


223 


530 


81 


61 


142 


226 


162 


388 


32 


30 


62 


36 


22 


58 


801 


537 


1338 


302 


214 


516 


186 


109 


295 



Since the last preceding report the Asylum has been so much crowded with 
patients that 141 applicants were rejected. Hence Dr. Stribling requests the 
Board of Directors to " again invoke the attention of the general assembly to 
the subject of founding another asylum for the insane," and expresses his con- 
firmed opinion that if another institution of the kind be determined upon, it 
should be placed in that part of the State which is west of the Alleghany 
Mountains. 

Dr. Stribling has frequently been called from his hospital duties, by sub- 
poena, to act as an expert in courts of law. " The Board of Directors, perceiv- 
ing the evil likely to result therefrom to the interests of the asylum, presented 
the subject, in their report for 1843, to the legislature, and asked ' that this 
officer be released from obligation of obeying such mandates, and that he be 
allowed, as some other officers of the Commonwealth, to give his testimony or 
opinion in the usual form of deposition/ The suggestion was promptly acted 
upon, and a law passed to that effect." Subsequently, upon receiving a sub- 
poena in a criminal case, he refused, under this law, to obey it. The question 
of the constitutionality of the law, so far as relates to criminal trials, was 
thereupon discussed before Judge Fulton, and he, in the language of Dr. Strib- 
ling, " sent his officer with an attachment to coerce my attendance. The 
attachment was not executed, only because, under the advice of learned and 
able counsel, I became satisfied that, in this case, at least, ' prudence was the 
better part of valour.' " 

Now, in our humble opinion, Dr. Stribling and his Board of Directors were 
wrong in the premises. We think that no superintendent of an institution 
should be exempt from obedience to a subpoena, in any case, either criminal or 
civil, in which his opinion as an expert is important to the issue. We have 
few experts of the kind. They are, almost without exception, connected with 
the institutions for the insane. Those institutions have, or ought to have com- 
petent assistant physicians. Thus, we believe that a law releasing the super- 
intendents from duty before legal tribunals, would be more seriously detri- 
mental to the cause of justice, and to the welfare of society, than useful to the 
inmates of the institutions over which they preside. 

10. From the few statistics of the reports of the State Lunatic Asylum of 
South Carolina, we select the following : — 

1853. 1855. 



Men. Women. Total. Men. Women. Total. 

Patients at the beginning of the year 135 174 

Admitted in the course of the year . 40 35 75 62 

Whole number in the course of the year 210 236 

Discharged, including deaths . 38 65 

Kemaining at the end of the year . 91 81 172 86 85 171 

Discharged cured .... 22 18 

Died 9 31 



1856.] 



Brown- S£quard ; Spinal Cord. 



301 



In regard to the mortality in 1855, Dr. Trezevant says: "We have lost 31 
patients : 15 of these, from their enfeebled state, would have died under any 
circumstances, but their death was hurried on by the improper accommoda- 
tions of the house, and the unwholesome condition of the yard. The rest suffered 
from bowel complaint, then prevailing, and were the victims of our want of 
proper ventilation and arrangements. * * * In dry seasons the mortality 
is about five per cent., but in wet it has been equal to about one in three. In 
the present year the bowel affections commenced with the rainy season, con- 
tinued whilst it lasted, and ceased when the earth was no longer saturated with 
moisture." 

We have carefully perused the reports before us, and find therein but little 
which comes within the scope of our notices, while that little is upon subjects 
already fully laid before our readers. The chief burthen of the reports from 
this institution, for several years past, consists of an exposition of the imper- 
fections of the Asylum, and the necessity of a new one. The building is old, 
and imperfect in its architectural construction and arrangements. Its grounds 
are too limited, and are immediately surrounded by dwelling-houses of citizens 
of Columbia. It appears that one or more of its wards are so damp as seriously 
to affect the health of the inmates. The whole is so much crowded that, as 
stated in one of the reports, there are fifty patients more than can be properly 
accommodated. The heating and ventilation are bad. There are no proper 
arrangements of baths and water-closets. In short, judging from the reports, 
the whole establishment stands but as a representative of the past. It is 
acknowledged as such by the Regents, the Physician, and the Superintendent. 
This has been granted for years. The question, therefore, has been, What shall 
be done ? We have exposition after exposition of the defects. We have sug- 
gestions for erecting additional buildings to those which now exist. We have 
propositions to erect an entirely new establishment upon the lands now occu- 
pied. We have argument upon argument to prove that a new structure should 
be erected more remote from the town. And yet the question is — What shall 
be done? There is a liberal appropriation yet unexpended. Different models 
have been presented for the new edifice. One of these is preferred and highly 
extolled by one party, but rejected and condemned in the strongest terms by 
another. And still, alas! still the question is — What shall be done? And the 
relic of the past, with " all its imperfections on its head," continues unmolested, 
and its inmates rejoice in the comforts of antiquity, because the powers that 
be cannot agree upon a substitute. 



Art. XV. — Deux Mimoires sur la Physiologie de la Moelle Epinilre, his d VAca- 
demie des Sciences, le 27 Aotit et le 24 Septembre, 1855. Par le Docteur E. 
Brown-Sequard. Laureat de TAcademie des Sciences, etc. etc. 8vo. pp. 42. 
Paris, 1855. 

Recherches Expirimentales sur la transmission croisee des Impressions Sensitives 
dans la Moelle Epinitre. Par le Docteur E. Brown-Sequard, etc. etc. 8vo. 
pp. 19. Paris, 1855. 

Proprietes et Fonctions de la Moelle -Kpinie're : Rapport sur quelques Experiences 
de M. Brown- Sequard. Lu a la Societe de Biologie, le 21 Juillet, 1855. Par 
M. Paul Broca, Professeur Agrege" a la Faculte de Medecine, etc. 8vo. pp. 
. 35. Paris, 1855. 

Two Memoirs on the Physiology of the Spinal Cord, read to the Academy of 
Sciences, August 27 and September 24, 1855. By E. Brown-Sequard, M. D. 

Experimental Researches into the Decussation which takes place in the Transmission 
of Sensitive Impressions through the Spinal Cord. By E. Brown-Sequard, 
M. D. 

Properties and Functions of the Spinal Cord : A Report on some Experiments of 
M. Brown-Sequard. Read to the Biological Society, July 21, 1855. By M. 
Paul Broca, 

The recent investigations of Dr. Brown-Sequard have thrown very import- 
ant light on the physiology of the spinal cord, especially on the manner in 



202 



BibliograjpMcal Notices. 



[July 



which sensitive impressions received by the different portions of the body are 
transmitted, through it, to the brain. 

While the fact is now, apparently, well established, that the posterior roots 
of the spinal nerves are the sole route for the transmission of sensitive im- 
pressions to the sensorium, there still continues to exist much diversity of 
opinion as to the portion of the spinal cord through which these impressions 
are conveyed to the brain. According to Backer, Kuerschner, and Longet, it 
is solely by the posterior fasciculi of the cord. Bellingeri refers the trans- 
mission to the central and Stilling to the posterior portion of the gray sub- 
stance alone, while Ludwig Tiirck refers it to the lateral fasciculi. Eigenbrodt, 
while he describes the posterior fasciculi as the principal medium of transmis- 
sion, believes that it may also take place through the gray substance, probably 
by the white fibres contained in this portion of the cord. According to Schiff, 
both the gray substance and the posterior fasciculi are the media of transmis- 
sion, and one of these portions of the cord may supply the action of the 
other. Rolando and Calmeil suppose that every portion of the spinal cord 
is capable of transmitting sensitive impressions to the brain. 

This diversity of opinion in reference to a subject that would appear, at first 
sight, so easy to determine by experiment, Dr. Brown-Sequard supposes to 
have arisen from ignorance on the part of the experimenters of one or other, 
or several of the following circumstances : — 

1st. The existence of reflex movements. 

2d. The decussation which occurs in the transmission through the spinal 
cord of sensitive impressions. 

3d. The possibility of this transmission being made by parts devoid them- 
selves of sensibility ; and, 

4th. The possibility of exposing the spinal cord, without causing an exces- 
sive loss of blood, and without exhausting the sensibility of the animal. 

By a series of well devised and skilfully executed vivisections, Dr. Brown- 
Sequard has very clearly demonstrated that, it is not by the posterior fasciculi 
of the spinal cord that ultimately takes place the transmission to the brain 
of the sensitive impressions made upon the trunk and limbs, but by the gray 
substance of the cord, and especially by its central portion. 

Dr. Brown-Sequard has endeavoured to show, by a number of ingenious and 
very striking experiments, carefully made by him upon the living animal, and 
varied so as to avoid, as much as possible, all sources of error, that the trans- 
mission of sensitive impressions through the spinal cord is made, in great 
part, if not entirely, in a decussative manner ; that is to say, the impressions 
that come from the right side of the body are transmitted to the brain by the 
left half of the cord, and vice versa. 

The general conclusions deduced from these experiments, and verified by 
numerous pathological facts, are as follow : — 

1st. The decussation of the elements by which sensitive impressions are 
conveyed to the brain, does not take place, as it has been asserted, at the 
anterior extremity of the spinal protuberance. 

2d. The gray substance of the cord does not possess the property, as some 
physiologists pretend, of transmitting sensitive impressions in every direction. 

3d. The most part, if not all the elements by which sensitive impressions 
are transmitted, decussate in the spinal cord ; that is to say, those coming 
from the right half of the body pass into the left half of the cord, and vice 
versa. 

4th. The decussation of these elements occurs, in part, almost immediately 
after their entrance into the spinal cord ; a few of them decussate at a cer- 
tain distance above the place of entrance, while others, on the contrary, and 
much the greatest number, descend into the cord and decussate a certain dis- 
tance below the point of entrance. 

5th. If there be some of the elements by which sensitive impressions are 
transmitted that ascend from the limbs or trunks along the entire course of 
the spinal cord to make their decussation in the brain, their number must be 
very inconsiderable. 

6th. The lesions capable of producing a paralysis of sensibility, seated at 



1856.] 



Brown-Sequard. Spinal Cord. 



203 



any point of a lateral half of the cerebro-spinal centre, produce always the 
paralysis of sensibility in the opposite side of the body. There is no differ- 
ence, in this respect, between the brain and spinal cord, as has heretofore 
been supposed. 

In a more recent memoir, Dr. Brown-Sequard describes a series of further 
vivisections, which, besides confirming the correctness of the general conclu- 
sions in reference to the functions of the spinal cord deduced by him from 
his former experiments, have conducted to results, in reference to the organiza- 
tion and physiology of that important organ, of a character at once novel and 
highly interesting. 

In previous experiments. Dr. B. S. demonstrated that when the two poste- 
rior fasciculi of the cord are divided transversely, both the divided surfaces 
remain sensible. This fact would appear to prove, contrary to what physio- 
logists have universally admitted, that the transmission of sensitive impres- 
sions may take place, in the posterior fasciculi of the cord, in two opposite 
directions. The following experiment performed by Dr. B. S., leads, on this 
question, to results much more positive : — 

" In a dog. cat, or full grown rabbit, we divide transversely the two posterior 
fasiculi of the spinal cord, at the inferior portion of the dorsal region ; we 
then dissect these fasciculi from the divided edges, longitudinally, for the dis- 
tance of two or three centimetres, so as to separate from the surface of the 
cord that distance, two laminae, continuous, the one by its superior, and the 
other by its inferior extremity, with the rest of the cord. The sensibility 
persists, but weakened, in both of the separated laminae, and we have verified 
the fact a great number of times, since 1852 when we first announced it, that 
the inferior lamina appears to be more sensitive than the superior." 

Subsequently, Dr. B. S. has varied this experiment, by taking two animals 
of the same species, and in each separating a single lamina from the surface 
of the posterior fasciculi, leaving it continuous with the cord at its upper ex- 
tremity in the one, and at its lower extremity in the other. In comparing the 
sensibility of the laminae in the two animals, it was found, as in the preceding 
experiment, that the one which remained attached to the cord by its lower 
end, exhibited a greater degree of sensibility than the other. 

If, remarks the Doctor, we dissect up laminae comprising not only the pos- 
terior fasciculi, but also a part of the lateral fasciculi of the posterior gray 
cornua, we find the sensibility to be much more acute in the two laminae 
than when they are composed only of the posterior fasciculi. The length of 
the flaps has also a considerable influence upon the degree of their sensibility. 
The shorter they are the greater their sensibility. "When over four or five 
centimetres in length, they have scarce any sensibility near their free ex- 
tremity. 

It is evident that the impressions made upon the free extremity of a flap 
detached from the posterior fasciculi of the cord, excepting at its lower end, 
must be centrifugal, and as, in those fasciculi, the only nervous element we can 
detect for the transmission of sensations are fibres, it therefore results, ac- 
cording to Dr. B. S., that fibres, capable of transmitting sensitive impressions 
in a centrifugal direction, exist in the posterior fasciculi of the spinal chord. 
By the following experiments, he shows that these fibres merely pass in the 
posterior fasciculi, and after a short course pass out again and penetrate the 
gray matter. 

"\Ve divide, transversely, the posterior fasciculi on a level with the tenth 
dorsal vertebra, and from the surface of these fasciculi, below the section, we 
separate a flap of about two or three centimetres in length, and leave it 
attached to the cord by its inferior extremity. Having assured ourselves that 
this flap retains its sensibility, we then divide transversely the two posterior 
fasciculi, at the distance of one centimetre below the spot where the flap is con- 
nected with the cord, and we find that the flap is deprived of all or nearly all 
its sensibility. 

"If, in place of making the second section at only one, we make it at five or 
more centimetres below the spot at which the flap remains continuous with the 
cord, we find that the sensibility of the flap continues unimpaired. In this 



204 Bibliographical Notices. [July 

case, the fibres for centrifugal transmission have quitted the posterior fasciculi 
to pass into another portion of the cord, because the second incision did 
not reach them, as it did in the first case, where they were all or nearly all 
divided/' 

The fibres referred to it is evident, therefore, quit, after passing a short dis- 
tance, the posterior fasciculi ; whence go they ? The following facts show that 
they pass into the central gray substance. 

"If in three animals, after having separated a flap from the posterior fasci- 
culi of the cord, adherent by its inferior extremity, we divide transversely, at 
about four or five centimetres anteriorly to the flap, in one of the animals, the 
lateral fasciculi, in a second, the anterior fasciculi, and in the third, the gray 
substance, we find that, in the last animal, the sensibility of the flap is de- 
stroyed, while it still continues in the other two. But if we divide in these 
the central gray substance, on a level with the spot at which the flap is con- 
tinuous with the cord, the flap is deprived of its sensibility." 

It is therefore in the central gray substance that pass the descending fibres 
of the posterior fasciculi, or those for centrifugal transmission. Analogous 
experiments show that in the flaps of the posterior fasciculi that adhere by 
their superior extremity, the ascending fibres, or those for centripetal trans- 
mission quit, also, very soon the posterior fasciculi to penetrate into the cen- 
tral gray substance of the cord. 

" The foregoing experiments," remarks the Doctor, "would seem to author- 
ize the following conclusions : — 

" 1st. That there are two species of sensitive fibres in the posterior fasciculi 
of the cord : the one ascending, or for centripetal transmission ; the other 
descending, or for centrifugal transmission. 

"2d. That in the posterior fasciculi, either the descending fibres are more 
numerous than the ascending, or they are capable, under certain circumstances, 
of inducing a greater amount of pain than the ascending fibres. 

" 3d. That the ascending as well as the descending fibres merely pass into 
the posterior fasciculi, and after running along them for a short distance, come 
out again to penetrate into the central gray matter of the cord." 

Dr. B. S. has shown, by direct experiment, that a considerable number of 
the ascending and descending fibres are derived from the posterior spinal 
nerves ; or, in other words, immediately upon their arrival in the cord, these 
nerves send fibres into the posterior fasciculi, of which a portion pass towards 
the brain, while another portion take an opposite direction. But all of these 
fibres quit soon the posterior fasciculi to penetrate into the central gray sub- 
stance of the cord. The following experiment shows that they pass from the 
right posterior fasciculus to the left portion of the gray matter. 

" In a rabbit we divide a lateral half of the cord, transversely, on a level 
with the first lumbar vertebra, and then cut longitudinally the cord to the 
extent of two centimetres in the direction of its antero-posterior plane, down- 
wards from the transverse section, and at a right angle with it. A small portion 
of the cord is thus separated at every part excepting its inferior extremity. In 
another rabbit we in the same way separate a small portion of the cord at 
every part excepting its superior extremity. Thus, in the first rabbit the im- 
pression, when the posterior nerves that are inserted in the partially separated 
portion of the cord, will be transmitted by the descending and in the second 
by the ascending fibres. If it is on the right side of the cord that the incisions 
have been made, and we divide, on the left side, the posterior fasciculus, at the 
distance of five centimetres above the part at which the first incision has been 
made, in irritating the posterior nerves which are inserted in the partially sepa- 
rated portion of the cord, we find them to be still sensible, but if, at the part 
where the left posterior fasciculus is divided, we cut through, transversely, the 
left lateral half of the central gray substance, the nerves referred to lose their 
sensibility." 

Experiments detailed by Dr. B. S., in which, after two transverse sections of 
the posterior fasciculi, made at a short distance from each other, sensibility has 
been diminished or lost in the posterior nervous roots included between the 
incisions, seem to prove that a considerable number of the fibres of these roots 



1856.] 



Brown-Sequard, Spinal Cord. 



205 



pass to the posterior fasciculi. Other experiments, in "which, after two transverse 
sections of the posterior fasciculi, the posterior roots, included between the 
incisions, retain in a striking degree their sensibility, would seem to show that 
the fibres of the nervous roots which pass by the posterior fasciculi, come out 
again after running a certain course. 

" The cut surfaces of the section of a segment of the posterior fasciculi, 
resulting from two transverse divisions of these fasciculi, appear/' remarks Dr. 
B. S., "always to differ, the one from the other, in their degree of sensibility; 
the greatest amount appearing to exist in the uppermost. 

" In the experiment performed by dividing transversely the posterior fasciculi 
in two places, very near to each other, we obtain a very curious result. We 
refer to the hyperesthesia which exists everywhere below the inferior section. Of 
the three segments which result from a division, at two points, of the posterior 
fasciculi, the upper or cephalic has a normal sensibility, the middle, a very feeble 
sensibility, and the posterior or caudal, an exaggerated sensibility. This exalted 
sensibility of the lower segment is always observed, excepting when the division 
has been made near to the caudal extremity of the cord, and it is, I may add, 
the greater in direct proportion to the size of the segment. 

" The state of sensibility in a segment of the posterior fasciculi, included 
between two transverse sections, has a direct relation with that of the nervous 
roots inserted in the segment, and of those portions of the body which derive 
their sensitive fibres from these roots. That is to say, when the sensibility of 
the fasciculi is diminished or augmented in a certain proportion, there is a 
corresponding diminution or augmentation in the nervous roots and all the parts 
of the body to which these send fibres. 

"If. as we have attempted to show, the fibres of the posterior nervous roots 
pass, in part, into the posterior fasciculi, we should find, after having divided 
transversely the entire cord, excepting the posterior cords, that sensibility 
persists, to a certain extent, in the posterior fasciculi and nervous roots, behind 
the section ; and such is actually the case, as we have shown in a preceding 
memoir. In this experiment, the posterior roots of the two or three pair of 
nerves that are immediately behind the point where the cord is divided, retain 
their sensibility through those of their fibres that pass by the posterior fasciculi. 
This is not the case, however, with the nervous roots situated at a greater dis- 
tance behind the point of division; their sensibility is lost, because, such of 
their fibres as pass by the posterior fasciculi have already quitted the posterior 
fasciculi and penetrated into the gray substance beyond the point of division. 

"The following experiment shows that the fibres of the posterior nervous 
roots which pass by the posterior fasciculi a short distance behind where the 
latter have been divided, again leave these fasciculi a short distance in front of 
the division. 

"In a cat or dog, after a transverse section of all the cord, save the posterior 
fasciculi, on a level with the tenth dorsal vertebra, we assure ourselves that 
sensibility persists in the posterior fasciculi, for the extent of some centimetres 
behind the point of division, as well as in the posterior roots of the two or three 
pair of nerves that are immediately behind this point. Then, upon one animal, 
at the distance of one centimetre, and in another, at the distance of five or six 
centimetres, in front of the first described section, we divide transversely the 
posteripr fasciculi ; in the first animal we find that sensibility is destroyed, 
while, in the second, it continues behind the part at which the first described 
section had been made. If, however, we divide, in this latter, transversely, the 
central gray matter, at the point where the posterior fasciculi had been divided, 
we shall find that the sensibility is lost." 

"It is probable/' Dr. B. S., remarks, "that certain fibres of the posterior 
nervous roots pursue a similar course in the gray cornua with those which go 
to the posterior cords, that is to say, after penetrating into the cornua, the 
fibres separate into ascending and descending, and after a short course penetrate 
the central gray substance. It is at least what may be rationally concluded 
from the following experiments : — 

"Before and behind the posterior roots of a pair of nerves, we thrust into 
the posterior gray cornua, in a direction perpendicular to the longitudinal axis 
1N0. LXlIL— July 185(3. 14 



206 



Bibliographical Notices. 



of the cord, a flat needle with a double cutting-edge, so as to cut the cornua 
transversely. We find subsequently that the posterior nervous roots betweeii| 
the four punctures made in the cornua have lost a considerable portion of their 
sensibility." 

" We divide, transversely, on a level with and anterior to the last pair of 
dorsal nerves, the greater portion of the fibres of the posterior fasciculi, saving, 
as much as possible, the surrounding gray substance. We afterwards perform 
the same operation behind the second pair of lumbar nerves ; so as to comprehend 
three pair of nerves between the two divisions. The sensibility we find still 
persists sufficiently acute in the posterior nervous roots intermediate to the 
points of division. If now the two sections are enlarged laterally, so as to 
divide the remaining fibres of the posterior fasciculi as well as the posterior 
gray cornua, the sensibility is diminished in a manifest degree in the nervous 
roots referred to. If, in addition to the sections already made, we also divide 
a considerable portion of the lateral chords, we find that these roots lose, still 
more, their sensibility." 

From these experiments, it would appear that the posterior gray cornua as 
well as the lateral fasciculi, at least their posterior portion, are the parts for the 
passage of a certain number of the fibres of the posterior nervous roots. In 
regard to the lateral fasciculi, this conclusion is rendered still more probable 
by the following experiment: — 

"At two places, immediately before and behind the posterior roots of three 
pair of nerves, we divide, transversely, the posterior portion of the lateral 
fasciculi, taking care to avoid, as much as possible, the central gray substance 
and the posterior cornua, and we find that an evident, though not very consider- 
able diminution, occurs in the sensibility of the posterior roots of the three 
pair of nerves included between the divisions. The diminution of sensibility 
i3 much more evident when the two, or rather four sections, are so performed 
as to include only a single pair of nerves between them." 

The fibres of the posterior nervous roots that pass into the lateral fasciculi, 
as well as those which proceed to the gray cornua, are ascending or descending 
like those which go to the posterior fasciculi. Besides, the fibres of the nervous 
roots which pass a certain distance along the lateral fasciculi and the posterior 
cornua, quit soon these parts to penetrate into the central gray substance. 
These facts are demonstrated, in regard to the posterior cornua and lateral 
fasciculi, in the same manner as in reference to the posterior fasciculi. 

It would appear, then, that in the spinal cord, the posterior spinal roots are 
arranged very similar to the ganglionar root of the trigeminus nerve, which, 
as we are aware, is divided in the spinal protuberance and bulb, into three 
portions, of which two, of little size, are the one ascending, and the other 
transverse, while the third, the bulbar root, is very large, and descending. 

From the facts and reasoning Dr. B. S. has adduced, he believes that he is 
able to draw two series of conclusions, as follows: — 

' ' I. Conclusions relative to the distribution of the Fibres of the Posterior Nervous 
Boots in the Spinal Cord. — 1. The fibres of the posterior nervous roots appear 
to pass in part to the posterior fasciculi, and probably also, but in a very small 
number, to the lateral fasciculi. 

"2. The fibres of the posterior roots which pass to the posterior fasciculi, 
appear to proceed, in part, towards the brain, and, in part, in the opposite 
direction ; so the one portion are ascending, and the other descending. 

" 3. The fibres of the posterior roots which pass to the lateral fasciculi, seem 
also to be composed of two series, the one ascending the other desending. 

"4. In the posterior gray cornua, there appears to be, also, ascending and 
descending fibres derived from the posterior roots. 

"5. In the posterior and lateral fasciculi, as well as in the posterior gray 
cornua, the descending fibres appear to be more numerous than the ascending. 

" 6. The ascending and descending fibres derived from the posterior nervous 
roots appear, after passing for a short distance, to leave the posterior and lateral 
fasciculi, as well as the posterior gray cornua, to penetrate the central gray 
substance. 

"II. Conclusions relative to the transmission of Sensitive Impressions in the 



1856.] 



Nelaton, Clinical Lectures on Surgery. 



207 



Spinal Cord. — 1. On their arrival at the spinal cord the sensitive impressions 
pass by the posterior fasciculi, the posterior gray cornua, and probably, also, 
by the lateral fasciculi. 

"2. In these different portions of the cord, the sensitive impressions mount 
or descend, and, after a short course, towards the brain or in the opposite 
direction, they quit these portions of the cord to enter the central gray sub- 
tance, in which, or by which they are finally transmitted to the brain." 

The fifth conclusion of the first series is one which, according to Dr. B. S., is 
the least positively established of the six. In saying that descending fibres 
appear to be more numerous than the ascending, he wishes only to be under- 
stood as offering the probable explanation of the hyperesthesia of those portions 
of the body which are behind the point at which the posterior fasciculi of the 
cord have been divided transversely. He is aware that there are two other 
explanations that may be given of this phenomenon which possess perhaps equal 
probability. Thus, it is possible that it is a property of the descending fibres 
to possess a greater amount of sensibility than the ascending, if so it is not 
necessary to explain the fact referred to by supposing that there should be 
more descending than ascending fibres. It is very certain that there is a 
special cause of the hyperesthesia experienced, after a division of the posterior 
fasciculi, in the parts below that division, and consequently the descending fibres 
should cause more pain than the ascending in the experiments of Dr. B. S., 
because the properties of the descending fibres cannot be tested until after the 
posterior fasciculi, or one of them have been divided. 

"It is possible, then, that even though inferior in number, the descending 
fibres may cause a greater amount of pain than the ascending. Let the ques- 
tion be settled as it may in reference to the relative number of the different 
fibres, an important anatomical and physiological fact results from the facts 
reported in this memoir, it is that the posterior nervous roots of the cord, in 
the same manner as the great root of the trigeminus in the bulb, send into 
the cord sensitive descending fibres, or those for centrifugal transmission. 
Anatomy must decide as to the number — with respect to the question of the 
existence of these fibres, anatomy has already confirmed what vivisections so 
positively teach. We have seen, and the most skilful microscopists have like- 
wise seen descending fibres proceeding from the posterior nervous roots." 

D. F. C. 



Art. XVI. — Clinical Lectures on Surgery. By M. Nelaton. From Notes taken 
by Walter F. Atlee, M. D. Philadelphia: J. B. Lippincott & Co., 1855. 
8vo. pp. 755. 

This volume, according to the preface, " contains the publication of notes 
taken, during a period of three years, 1851-52-53-54, from the remarks made 
upon cases to which attention was particularly directed. The course adopted 
in their arrangement has been, as a general rule, to class under the same head 
those in which the same pathological lesion existed, though in some few in- 
stances, when the great interest of the case lies in the diagnosis, this plan 
has been departed from, and the case has been classed with others, from the 
fact that it was not one of them." 

The preface further informs us that the additions of the editor "are so placed 
as to be at once distinguished. This has been done very rarely, in fact almost 
solely, in order to make the work as respects surgical pathology more complete, 
by stating the results of microscopical investigations. These results have 
been taken from the works of M. Charles Robin, and of M. Lebert." 

The title of the work, although not altogether in accordance with the state- 
ments of the preface and the actual contents, must insure for it an amount of 
attention, which we are glad to say there is much to gratify in the notes of which 
it is composed. Clinical lectures are always interesting ; and the name of 
Nelaton as the lecturer is at present so attractive, that almost any report of 
his hospital teachings would be eagerly sought after by a numerous crowd of 
admirers in this country. We remember him ten years ago in the very same 



208 



Bibliographical Notices. 



[July 



field of labour, which he has since rendered so pre-eminent, as even then one 
of the best and most popular lecturers on his branch, although Berard and 
Blandin, Lisfranc and Roux, as well as the now veteran Velpeau, were still 
in full vigour and activity. We have read the notes of Dr. Atlee, therefore, 
with unusual interest. They do great credit to his industry and enterprise ; 
and we are satisfied that they are unusually full and faithful, and may afford 
an excellent idea of the distinguished clinical professor's mode of teaching, as 
well as of much of his theory and practice. 

We regret, however, that they have been left to work their way without the 
guarantee of authenticity, if not of special authority, which is naturally looked 
for in a production of such extent and character. The very high reputation of 
the author of the lessons which they are understood to represent, and the con- 
sequent importance of the doctrines and experience which they exhibit, ob- 
viously increase the necessity for accompanying their publication with some 
kind of token, on the part of M. Nelaton, of assent to their appearance, and 
of affirmation of the facts and opinions which they impute to him. 

We understand that the desired approval was obtained by Dr. Atlee, and 
that accident alone has hitherto prevented its announcement. A voucher to 
this effect would certainly very much enhance the value of the work, and give, 
in many eyes which now view it with distrust, an entirely different aspect to 
an offering which has been too handsomely produced, and has cost too much 
valuable time and labour, to be presented under any but the most favourable 
auspices. It is to be hoped, therefore, that the objection may be removed in 
the next edition. This seems to be all the more needful, because new or pecu- 
liar modes of practice in treatment and operations, and independent views of 
pathology and therapeutics, may be met with here and there, which must 
prove rather startling to the previous notions of many readers. A few of these 
might be dwelt upon to more or less advantage in our notice ; and we might 
be tempted to risk a doubt or two, so- far as this country is concerned, in rela- 
tion to some others, did they come before us more directly from their author. 

Several of the cases which suggested peculiarities of practice or pathology, 
are unfortunately inconclusive, because, owing to various impediments, no re- 
sults were ascertained. The value of a number of the observations is seriously 
impaired, in this way; many cases of interest — not a few decidedly important — 
being abruptly terminated through the disappearance of the patient, or the 
withdrawal of the lecturer or reporter. Others may be noted also, which, 
although natural enough in the course of an every-day clinique, and proper 
enough, perhaps, in an elementary text-book, seem hardly to be entitled to the 
space they occupy in a collection of selected cases. They were certainly not 
required to establish either the interest or completeness of the series. We do 
not say this in a fault-finding spirit ; we are not the first to make these remarks, 
and we repeat them as a matter of duty, especially in behalf of that influential 
class of readers who regard a big book as a great evil. In our practical day 
and generation the worst of troubles in a book intended to be much and widely 
read, is too often in its own specific gravity: the deadliest foe to popular inte- 
rest in the nature of the matter of an author's pages, is its extra amount in bulk. 
As bulk, then, is one of the difficulties which is barely escaped in Dr. Atlee's 
volume, although doubtless fully overcome in its successful circulation, he will 
excuse us if, with a sincere desire to avoid disparagement, we express the belief 
that the matter which is added to the clinical notes for the purpose of pathological 
illustration might have been advantageously compressed into the form of foot- 
notes or appendices in smaller type. This appears to us especially desirable in 
the portions relating to the microscopical conclusions of the authorities cited in 
the preface, since these conclusions are not those of M. Nelaton himself ; nor 
do the recent investigations and discussions, in the French Academy and else- 
where, appear to aid in settling mooted points or in sustaining the weight of 
these authorities against him and his fellow-surgeons. We cannot help doubting 
the utility of such additions in a work which, as the Clinical Lectures of the 
Professor of Clinical Surgery in the Medical School of Paris, from notes taken 
in the wards or amphitheatre of the Clinical Hospital of that school, might 
be regarded, notwithstanding the qualifications of the preface, as intended to 



1856.] 



Dunglison, Human Physiology. 



209 



exhibit the precepts and practice of that Professor, and of him alone. In add- 
ing to the commentaries of M. Nelaton the editor runs the risk of a confu- 
sion, if not of conflict of opinions, which might materially change the character 
of his book. 

Still no one can fail to become deeply interested in its pages, or to be de- 
cidedly benefited by the many admirable hints on diagnosis and treatment 
afforded by the cases and comments which occur in the greatest profusion and 
variety, and are repeatedly presented in graphic and vivid colours. We take 
pleasure, therefore, notwithstanding some, perhaps immaterial, objections to 
one or two features of the publication, in recommending it to the careful study 
of advanced students and practitioners. To the latter, especially, it must prove 
not only very interesting but in the highest degree instructive, as we should be 
glad to show by a few extracts, had we space for them, and by a hasty glance 
at the headings of the principal chapters. 

Among the almost bewildering array of surgical diseases and injuries which 
are often forcibly and always usefully illustrated, in the twenty-three chapters, 
may be mentioned burns, contusions, wounds, and local disorders of different 
kinds, affections of the bloodvessels, cancerous and other tumours, abscesses, 
fractures, and luxations, diseases of the joints and of the bones, injuries of the 
head, affections of the eye and of the nose, affections of the soft parts of the 
face, of the neck, of the mammary gland, tumours of the abdomen, diseases of 
the anus, rectum, and intestines, of the male genital organs, of the bladder, of 
the female genital organs, affections of the foot. 

Under these separate heads almost the whole range of ordinary practice, to- 
gether with much that is by no means of every-day occurrence, even in hospital 
experience, is presented in an agreeable and familiar and, as already intimated, 
often particularly clear and striking manner. M. Nelaton's happy faculty of 
teaching principles, as well as his lucid modes of demonstration, are well retained 
by Dr. Atlee in his notes. Indeed, in spite of frequent Gallicisms and occasional 
obscurities of language, the extreme literalness of the translation increases its 
genuineness to us, and affords the strongest evidence of the fidelity of the 
reporter. The very Gallicisms in words and phrases are full of associations 
with the lecture-room in which they were originally taken down, and recall to 
our mind the language of the lecturer more forcibly than the purest English 
that could be written. Let us not be understood to be the apologist for errors 
of revision, which we doubt not will be fully atoned for in a future effort. 
These are minor blemishes, although annoying to many readers and injurious 
to the reputation of a translation, but they are not serious enough to inter- 
fere with the legitimate uses of a scientific work intended solely for profes- 
sional men who ought to be familiar with the language from which they are 
derived. 

Our thanks are due to the publishers for the handsome style in which the 
volume is produced. It would be gratifying to see their example on this occa- 
sion more frequently followed. E. H. 



Art. XVII. — Human Physiology. By Roblet Dunglison, M. D., LL. D., Profes- 
sor of the Institutes of Medicine in Jefferson Medical College, Philadelphia, 
etc. : " Vastissimi studii primas lineas circumscripsi." Haller. With five 
hundred and thirty-two illustrations. Eighth edition, revised, modified, and 
enlarged. Two volumes, 8vo. pp. 729-755. Philadelphia, 1856 : Blanchard 
and Lea. 

In the notice of a scientific work, which, in the midst of a host of contempo- 
raries of high reputation, has already reached to its eighth edition, it would be 
a work of supererogation to enter into a formal criticism of either its matter 
or its plan. It has, unquestionably, been found to answer, in a good degree at 
least, the purposes for which it was originally prepared, and to keep pace with 
the progress of discovery and elucidation in its particular department, or the 
call for edition after edition would not have been made. A very inferior treatise 



210 



Bibliographical Notices. 



[July 



on physiology, or one behind the knowledge of the day, would not have been 
tolerated, when so many others of acknowledged value were at hand to supply 
its place. 

In a work which, like the one before us, is chiefly valuable as a correct and 
satisfactory exponent of the actual state of physiology, deduced from the ob- 
servations and experiments of preceding and contemporary investigators, we 
are not to look so much for originality of matter as for fulness, accuracy, and 
impartiality, in the exposition of the labours of the most reliable cultivators of 
the science, and for clearness and system in the arrangement and treatment of 
the subjects embraced in it ; so that it shall present a faithful and useful re- 
flection of received facts and doctrines, with, of course, the views of its author 
on all those questions that still remain problematical, or, in regard to which 
a difference or opposition of opinion is entertained by authorities of equal 
weight. 

In this latter point of view, the treatise of Dr. Dunglison is one admirably 
calculated to meet the wants of the student of human physiology. The author 
has, with commendable industry, noted the new facts, as well as the modifica- 
tions of those previously recorded, that are due to the labours of the more 
recent physiologists, and the changes that, in consequence, the before received 
explanations of vital phenomena have undergone ; these, with its clear exposi- 
tion of the established truths and doctrines, render the present edition as fair 
an expression as can be desired of the physiology of the day — such as it has 
been rendered by the labours of a host of energetic and discriminating inves- 
tigators. 

We may, it is true, in a careful analysis of the work, find ourselves obliged 
to differ from the author as to the validity of one or two of the opinions he has 
drawn from established facts, and, occasionally, to accuse him of having given 
undue importance to certain series of observations and experiments, and the 
doctrines based upon them ; as a whole, however, we can candidly say, that we 
know of no treatise better adapted for the use of the medical student, or of 
those who, although they are not preparing themselves for admission into the 
ranks of our profession, may desire, nevertheless, to become acquainted with 
the vital laws and phenomena of the human organism. 

The work is well and richly illustrated ; for several of the illustrations con- 
tained in former editions, others of a superior quality have been substituted, 
while about sixty entirely new ones have been added. D. F. C. 



Art. XVIII. — A Practical Treatise on the Diseases of the Testis, and of the Sper- 
matic Cord and Scrotum. With numerous wood engravings. By T. B. Cur- 
ling, F. R. S., &c. &c. Second American, from the second revised and 
enlarged English edition. Philadelphia: Blanchard & Lea, 1856. 8vo. pp. 419. 

Mr. Curling's admirable monograph has been the standard authority on its 
subject ever since it first appeared some twelve or thirteen years ago. The 
new edition may be safely recommended as not only sustaining, but decidedly 
surpassing the reputation of the old one in all the characteristics of a classical 
treatise, and in none more than in its practical tendencies. The peculiarly 
happy qualifications of the author for the preparation of such an essay, have 
evidently been at work in enabling him to make the utmost of the unusual oppor- 
tunities afforded by the long interval between the two editions, and by the 
immense field of observation and research within his reach. Those who are 
familiar with the original work, superior as it was to all of its predecessors, 
cannot fail to be satisfied that the evidence of progress presented by the volume 
before us is fully in proportion to the advance of practical science generally, 
if not greater than there was reason to expect in a work already so complete 
in most respects and confined to the disorders of a single organ. 

This is the impression which a careful comparison of the first and second 



1856.] Curling, Diseases of the Testis, Spermatic Cord, and Scrotum. 211 



issues, of which both English and American copies are now upon our table, 
has made upon ourselves. The whole book has been subjected to a laborious 
revision by its able author; and has been correspondingly improved in style 
and arrangement, as well as in the addition of a large amount of valuable 
matter. In the course of this improvement new chapters have been added, 
many have been rewritten, and as the preface very modestly ventures to hope, 
nearly all of them contain additional facts of practical interest and importance. 
In order to accommodate the fresh matter and additional wood-cuts without 
increase of bulk, the introductory part on the anatomy of the testis is omitted 
in the London and New York copy. A smaller type and larger page have 
enabled the Philadelphia publishers to retain this section in their edition, with- 
out making their volume as large as the other, at the same time that some notes 
and several extra illustrations have been introduced by Dr. W. H. Gobreoht, 
who was called upon to incorporate the cases of the author's appendix in the 
text, and to supervise the passage of the latter through the press. 

We find upon examination, that notwithstanding the retention of nearly 
twenty pages on the anatomy, including seven wood engravings, together with 
three brief notes and eight new wood engravings in the remaining chapters, 
the American reprint occupies just one hundred pages less than the London 
and New York original. It should be said also that the paper and printing of 
the American edition are as good as usual, and the execution of the wood-cuts 
is all that need be desired — quite equal to that of their prototypes from the 
hands of the English artists. 

It is difficult to make selections where there is so much to engage the pro- 
fessional reader. Nor is it much easier to point out the portions of the volume 
which, either on account of novelty or practical interest, may seem to demand 
especial notice. Without attempting such distinctions, we may say that in 
glancing over the pages our attention has been arrested by Chapter I., On 
Congenital Imperfections and Malformations — particularly Sect. III., On Im- 
perfect Transition of the Testicle; Chaper IV., On Hydrocele; Chapter VI., 
On Orchitis, and particularly Sect. II., On Chronic Orchitis ; Chapter VII., On 
Tubercular Disease of the Testicle ; Chapter VIII., On Carcinoma of the Tes- 
ticle ; Chapter XIX., On Castration ; Chapter I. of the part on Diseases of the 
Spermatic Cord, On Hydrocele : Chapters IX., X., XL, of the Third Part, On 
Diseases of the Scrotum, occupied with adipose, fibrous, and cystic Tumours 
of the Scrotum. The chapters just enumerated are but a few of the thirty-four 
which are worthy of study as containing much that is not to be found in the 
pages of the former edition. They may serve in some degree to show the 
nature of the advance made by the author in his twelve years' inquiries and 
records in relation to the subject of his elaborate and most instructive work. 
In addition to his own valuable accumulations, Mr. Curling was enabled to 
avail himself of the manuscript copy of a prize essay on the diseases of the 
testis, by Mr. Harvey Ludlow, a young and promising surgeon, recently a victim 
of the Eastern war at Scutari. Valuable tables and cases of interest well 
observed and recorded in this essay, are quoted and handsomely acknowledged 
by our author. 

. We conclude our notice with two or three extracts which appeared to be 
sufficiently interesting to reward a perusal here ; at the same time that they will 
afford a very fair idea of the general tone and style of the book. 

His remarks upon the use of the seton in the treatment of hydrocele were 
especially acceptable to us, inasmuch as they speak well and to the purpose of 
a remedy for which we have been taught to entertain more respect than is 
generally accorded to it: — 

" The seton is a better mode of treating hydrocele than the other plans 
which I have described; but though a remedy less severe than these, it is not 
free from the same objection, of being very liable to produce more inflamma- 
tion than is requisite for the cure of the complaint. It is, however, a very use- 
ful remedy in certain forms of the disease, and in vaginal hydrocele under 
certain circumstances. The plan I adopt is to pass an ordinary curved needle, 
armed with a single or double silk ligature, through the skin and sac in front, 
leaving a space of an inch or an inch and a half between the ends of the liga- 



212 



Bibliographical Notices. 



[July 



ture, which may be tied Loosely together to prevent the seton escaping. The 
two or four threads should be sufficient to fill up the apertures made by the 
needle, and thus prevent the admission of air and escape of blood. The fluid 
in the sac then drains away along the threads. Inflammation of the sac soon 
arises, and causes fibrinous exudation. This is known by the greater solidity 
of the tumour, and it is then necessary to remove the threads, usually from the 
second to the third or fourth day after the operation. The inflammation and 
swelling afterwards subside, and the hydrocele is permanently cured by adhe- 
sion. In this way of employing the sefcon, the sac is disturbed much less than 
in the ordinary method, and the inflammation excited is usually mild. I have 
resorted to it in many cases of encysted hydrocele of the cord and testicle ; 
and as the tumour in these cases is usually small in size, the seton proves the 
best means of cure. In cases of simple hydrocele, after the failure of injec- 
tions by others, I have also used the seton with success, and I have tried it too 
in cases where no other treatment has been adopted. The great objection to 
its use in simple hydrocele is the uncertainty of its operation. I have gene- 
rally found it both a sure and gentle remedy, though occasionally I have been 
disappointed by its producing high inflammation, which it was impossible to 
control, and which speedily ran on to suppuration." (p. 132.) 

As appendix to the foregoing, it will be useful to add the following summary 
view : — 

"A careful inquiry into the merits of the various modes of effecting the 
radical cure of hydrocele fully establishes the superiority of the treatment by 
injections, especially iodine. The older surgeons committed a great error by 
endeavouring to excite too high a degree of inflammation ; for, not perceiving 
that the disease could be arrested by altering the action of the vessels of the 
part, they sought to obtain the closure of the natural cavity, which, moreover, 
they endeavoured to effect by producing suppurative inflammation and granu- 
lation, instead of by the gentler process of adhesion. The improvement in 
treatment consists in reducing the amount of inflammation to the lowest possi- 
ble standard, the chief risk incurred arising from the plans employed proving 
too mild to be efficacious and sure. Injection has now been largely tried in 
this and other countries; and experience warrants us in asserting that, though 
it is not an infallible remedy, of all the plans hitherto practised it combines 
the greatest number of advantages. The pain attending it is slight ; its effects 
are mild, and at the same time tolerably sure; if properly performed, it is free 
from danger ; and it frequently succeeds without altering the natural condition 
of the parts. I know it is a question whether the cure by adhesion, though 
less perfect than that in which the disposition merely of the vessels is changed, 
is not upon the whole preferable. In the latter there is a possibility, if not a 
probability, of a relapse at some future period, the causes conducing to hydro- 
cele still remaining ; whilst the inconvenience produced by an impediment to 
the free movements of the testicle, in cases cured by adhesion, is regarded as 
too trivial to be any disadvantage. But, in the absence of data showing the 
degree to which the disease is liable to return after the cure without adhesion, 
I feel perfectly satisfied with such a result, and much prefer leaving a patient 
exposed to the doubtful chance of a relapse, than subjecting him to severer 
treatment in order to make sure of exciting sufficient inflammation to secure 
adhesion and obliteration of the sac. Injections, however, are not capable of 
effecting a cure in every case, nor are they adapted for every constitution. 
The judicious surgeon, therefore, whilst resorting to them as his ordinary 
remedy, will be prepared to avail himself, in particular and difficult cases, of 
other means more certain in their effects, such as the seton and incision." 
(pp. 141, 142.) 

Next we present a long but curious and instructive account of spermatozoa 
in encysted hydrocele. 

" In investigating the history of the cases of encysted hydrocele containing 
spermatozoa which came under my notice, I found in a majority of instances 
that the swelling had gradually formed after an injury to the testicle; and in 
two cases it was clear that a small cystic swelling had long existed in a station- 
ary state, but after a slight blow hud enlarged. So that it was most probable 



1856.] Curling, Diseases of the Testis, Spermatic Cord, and Scrotum. 213 



that a duct had been ruptured by the contusion, and that the irritation conse- 
quent on the injury, and perhaps on the addition of the spermatozoa to the fluid 
contents of the cyst, had led to its further growth. After several attempts to 
establish by anatomical examination the existence of a communication between 
the duct and the cyst of the hydrocele, which failed owing to the difficulty of 
injecting the tubes in the head of the epididymis, I have recently, with the 
assistance of Mr. John Quekett, succeeded in detecting a communication in 
two instances. A man, aged fifty-three, died in the London Hospital in July, 
1854. His testicles being enlarged, were removed. On laying open the tunica 
vaginalis, I found a cyst containing about four drachms of milky fluid attached 
to the head of the epididymis in both testicles. At my request Mr. Quekett 
inserted a tube into the vas deferens, and injected the glands with mercury. 
The metal passed into the epididymis, and escaped freely into the cyst attached 
to it in both organs. The ducts of the epididymis, loaded with mercury, were 
found ramifying over the walls of the cyst, having been drawn out and ex- 
panded by the growth of the hydrocele. On examination of the interior of the 
cysts, the open mouth of the duct from which the mercury had escaped was 
distinctly visible. There was an oval opening in the membrane of the cyst, 
the edges of which were even and rounded, and at a point in the centre of 
this opening globules were seen escaping from a minute aperture in one of 
the ducts. The open mouth of the duct, into which a bristle has been passed, 
may be distinctly seen in the preparation. 

" The examination of these two testicles affords the true solution of the diffi- 




A. Vas deferens. C. Testicle. D. Epididymis, with the ducts expanded over the cyst. E. Cyst. 

culty which has hitherto existed in satisfactorily accounting for the presence 
of spermatozoa in encysted hydroceles. It appears that as the hydrocele in- 



214 



Bibliographical Notices. 



[July 



creases in size, the delicate tubes are drawn out and extended over the cyst, a 
position in which they are peculiarly exposed to accidental rupture. That the 
opening was of old standing, and not produced by the pressure of the column 
of mercury, is shown by the character of the aperture. It may be objected 
that if such a patent opening existed, the hydrocele should go on steadily in- 
creasing from the ingress of the spermatic fluid, and not remain stationary, as 
we often witness in these cases. We can readily conceive, however, that in 
the full distension of the cyst, the ducts would be so compressed and obstructed 
as to cause the seminal fluid to flow through the other efferent tubes. If the 
hydrocele were emptied by puncture, the channel would again become free, 
and fresh spermatozoa would then enter the cyst. In some instances the open- 
ing of the duct appears to become permanently closed, so that after the punc- 
ture of the cyst there is no return of the hydrocele, as in the following case. 
An old man consulted me on account of a large hydrocele which extended up 
to the abdominal ring, the testicle being situated at the bottom of the scrotum. 
It was on the right side, had been forming for eight years, and had never been 
tapped. I introduced a trocar, and drew off thirty-two ounces of a milky fluid, 
which contained myriads of spermatozoa. I saw him two months afterwards, 
and found a fulness on the right side of the scrotum from the collapsed sac, 
but there was no return of the hydrocele. 1 

" The ducts of the epididymis, when extended over the cyst, must not only 
be liable to rupture from a slight contusion, but also to be punctured in the 
operation of tapping ; and no doubt they are occasionally wounded in this 
way. This appears to have happened in the following case : A man, aged 
fifty-one, had an encysted hydrocele, which was tapped by one of my col- 
leagues, and about an ounce of limpid fluid was removed from two distinct 
cysts. He was again tapped by the same surgeon a month afterwards, and on 
neither occasion were any spermatozoa detected in the fluid removed. In a 
few weeks afterwards he applied to me in consequence of a return of the swell- 
ing, attended with a good deal of uneasiness. I performed acupuncture in 
three places, and in the drops of fluid which escaped, spermatozoa were found. 

" Spermatozoa are stated to have been found in some two or three instances 
in fluid removed from the tunica vaginalis. It is not improbable that these 
cases may have been encysted hydroceles mistaken for simple. The diagnosis 
is sometimes very difficult, and in the case of the cyst examined by Mr. Paget, 
this error was made before death by a hospital surgeon. I have, however, 
found spermatozoa in the sac of the tunica vaginalis, and the following case 
will account for their presence. A man, aged fifty-four, died in the London 
Hospital of disease of the kidneys, of one of the ureters, and of the bladder, 
which appeared to be consequent on a severe blow on the loins about six weeks 
before. The tunica vaginalis of one of the testicles contained two ounces and 
a half of slightly opaque fluid, in which a few spermatozoa were found. There 
were three small cysts containing fluid, immediately connected with the epidi- 
dymis, and also at one spot an irregular ragged membranous appearance, evi- 
dently caused by the rupture of a cyst. It is most probable that the sperma- 
tozoa had escaped from this cyst, which may indeed have been burst at the 
time of the injury. I have examined the fluid from the tunica vaginalis in a 

1 " The above explanation of the occurrence of spermatozoa in hydrocele is in com- 
plete accordance with the interesting observations of Professor H. Luschka in a Paper 
on the ' Appendicular Structures of the Testis' ( Virchow's Archiv. f. Path. Anat. u. 
Physiol., vol. vi. p. 310, 1854), with which I have only recently been made acquainted 
by Mr. Busk in a note in his recently published translation of Wedl's Pathological 
Histology, p. 465 (Syd. Soc.) Luschka states that the cavity in many cases commu- 
nicates so openly with the seminiferous canal that the hydatid may be taken to repre- 
sent a vesicular dilatation of the extremity of the latter, projecting beneath the epidi- 
dymis. The communication with the seminal tube when narrower can, however, 
always be demonstrated by the introduction of a bristle, or by mercurial injection. 
But not unfrequently no communication can be discerned, and in these cases the cysts 
contain no seminal elements. Professor Luschka seems to have found less difficulty 
in detecting the communication with a seminal tube than I experienced. 



1856.] Oesterlen, Manual of Materia Medica and Therapeutics. 



215 



large number of instances without finding these bodies, and I believe their 
occurrence in vaginal hydrocele to be extremely rare." (pp. 152-155.) 

" From these observations, it will appear that I consider the treatment by 
pressure to be applicable either for the cure or relief of the majority of cases 
of varicocele occurring in practice. Certainly, in all those cases in which tole- 
rably firm pressure with the fingers, at the abdominal ring, removes the sense 
of weight and uneasiness along the cord, this plan may be resorted to with 
every prospect of a beneficial result; and its simplicity, freedom from all risk, 
and efficiency, render it preferable to all operative modes of treatment. The 
truss should be applied whilst the patient is recumbent, so as to make rather 
firm pressure at the external ring. It sometimes happens that the truss, 
though worn with comfort after being adjusted in the morning, begins to pro- 
duce uneasiness towards the after part of the day. When this is the case, the 
pressure should be diminished by loosening the thigh-strap. In general, the 
truss should be worn only during the day, though in some instances I have 
thought it advisable to recommend its use during the night also. Thus, in one 
case the patient suffered uneasiness in lying on the side affected, and was able 
to pass a better night on wearing the truss. When the scrotum is unusually 
pendulous, or when the veins are very long and form a plexus of any size, I 
advise the addition of the silk net suspender, which may be readily adapted to 
the truss." (pp. 373.) 

Lastly, a short extract in regard to the treatment, radical as well as palliative, 
of varicocele, by pressure with a truss — in which Mr. Curling has had much 
experience and has met with great success. 

The truss which is above referred to is delineated and described on p. 366, 
and several cases in illustration are given on the succeeding pages in order to 
explain its method of application and beneficial operation. This plan of treat- 
ment and its rationale have been known to the profession through Mr. Curling 
for several years, but we suspect that they have not attracted the attention they 
deserve. We remember listening with great interest to a lecture on the subject, 
read by Mr. Curling ten years ago, at a meeting of the Medico-Chirurgical So- 
ciety of London. The report of this paper and the discussion on it were 
subsequently published and very generally quoted. His recommendation of 
the employment of the truss as he directs it for the removal of this common and 
vexatious infirmity, was no more decided then than it is now after a ten years' 
further trial. E. H. 



Art. XIX. — Manual of Materia Medica and Therapeutics. Sixth edition, revised 
and enlarged. By Prof. Fr. Oesterlex : published by Haupp & Siebeck, 
Tubingen, 1856. 

The author of the above manual has been long favourably known to the 
literary and scientific world, not only by this Materia Medica, but also by 
his work on Hygiene, one on Medical Logic 1 (a work alike important to physi- 
cian and naturalist), and various other productions. His manual of materia 
medica having in the course df a few years passed through so many editions, 
we may be allowed the conclusion that it must possess more than ordinary 
merits to commend it, for, considering the vast number of similar works, it 
could not otherwise have passed into the hands of so many thousands of 
readers in nearly every part of the world. 

We are all aware that there is scarcely a department of medicine, for the de- 
velopment of which we need the aid and co-operation of so many various col- 
lateral sciences (more especially chemistry, pharmacy, physiological and 
chemical medicine, natural history and the like), as in that of materia medica 
and therapeutics. Such difficulties can alone be surmounted by a mind pos- 
sessed of qualities, resources, and talents, such as are found united in the au- 

1 Published in English by the Sydenham Society. 



216 



Bibliographical Notices. 



[July 



thor of the book before us. Nor has there come under our eye a work on ma- 
teria medica, in which the doctrines derived from these auxiliary sciences have 
been brought into so intimate a relation and connection with the infinite mass 
of remedies, and with all the practical details, as in Oesterlen's manual ; in 
fact, in every chapter to which we turn, we discover that the author is as fami- 
liar with the natural sciences and physiology as with nosology and clinical 
medicine. 

From the great number of compendiums that have been published on this 
branch of medicine, it may not be irrelevant in the first place to inform the 
reader of what he will find in Oesterlen's work — in other words, what he may 
and may not expect ; for this reason we here annex a brief survey of its con- 
tents. 

In his Introduction, after considering definition, properties, and qualities, 
physiological and therapeutic actions of the various medicines and poisons, their 
manner of application and their classification, our author treats of the single 
substances in the following order : — 

1. Metals. 

2. Alkaline and earthy bases and their salts. 

3. Metalloids, such as sulphur, iodine, chlorine, and others. 

4. Acids. 

5. Bitter and astringent substances: iron and manganese. 

6. Volatile excitantia and stimulantia^such as aether, camphor, gethereal oils, 
balsams, &c. 

7. Vegetable acria. 

8. Narcotic substances and such as produce asphyxia. 

9. Indifferent nutritive substances (emollientia disetetica), such as fats, 
starch, and substances containing albumen and gum. 

10. Water. 

11. Mineral waters. 

12. Physical agents (imponderabilia), as heat, cold, cold water cure (hydro- 
pathy), electricity, galvanism, magnetism, electro-magnetism. 

A special appendix treats of dietetics, climates, gymnastics, and the like, and 
the work finally concludes with a large number of well chosen formulas, atoxi- 
cological table, and a collection of chemical tests for all of the most important 
substances. 

Besides its being so complete and comprehensive, what, in our opinion, more 
particularly distinguishes the work in question is, that the description of all 
these subjects, of themselves often so dry and tedious, appear in this book less 
tinctured with their dulness than is usual in manuals of this kind, and that 
his manner of elucidating his subject bespeaks a mind of the highest order, 
well stored with universal literary attainments, and endowed with a most pene- 
rating judgment. 

The botanic and pharmaceutic qualities of medicines, in a word their natural 
history, we find throughout the work, to be well though briefly described, but 
his chief stress the author lays on the modus operandi and the therapeutic ap- 
plication of all these substances, and in doing so, he has taken the science 
of materia medica in the sense and acceptation in which it should certainly 
be regarded by the physician and student, unless we intend to sacrifice it to 
the interest of the pharmaceutist. In this respect particularly, Oesterlen's 
Materia Medica differs from Pereira's, and from all other English works known 
to us on this subject; these have laid the chief weight on the natural history 
and pharmacy of substances. On the other hand, we find in Oesterlen's work, 
a more detailed and complete description of the actions and applications of 
medicines (so essential to the practitioner at the sick-bed), than is to be met 
with in any work on materia medica in the English language. 

To show that Oesterlen has at least partially traced out the right course, we 
may mention the fact, that in the short space of eight years his Materia Medica 
has passed through six editions (each including upwards of two thousand 
copies), and that it has now become at all the universities in Germany and 
among practising physicians a standard work. 

In every part of the book we find moreover a more careful and circumspect 



1856.] 



Dunglisoiij New Remedies. 



217 



use of English and American, as well as of German and French and other 
foreign literature, than is generally met with ; a literary and scientific appa- 
ratus so complete must prove indeed a welcome treasure to every reader. In 
confirmation of the above we have for instance only to refer to the chapters on 
mercury, iron, iodine, aetherization, cod-liver oil, cold-water cure (hydrothera- 
peutics), mineral springs, and so on ; a mere cursory perusal of these will lead 
him to the conviction that the chapters above referred to may well lay claim to 
the title of concise monographies — all, nevertheless, concentrated in one volume. 

In studying this work, the reader will become convinced sooner than from 
the study of any other similar work, that materia medica (therapeutics), like 
all other branches intimately connected with the natural sciences, has, in the 
course of time, undergone an almost entire revolution in respect to its founda- 
tions, principles, and scientific tendencies. The materia medica of the present 
day is not that of some twenty or even ten years' date ; the physicians, too, must 
nolens volens, follow the current of the age, the more surely as this but leads 
onwards and nearer to truth, the highest aim of medical science and art. 
Taking this view of the subject, Oesterlen appears to us the chief representa- 
tive, if not in many respects, even the author and originator of this system, or 
so to say, of this school ; in no other work on materia medica have we seen so 
many an illusion and delusion, so many a superstition of the old school of thera- 
peutics subjected to so consistent and so critical a scrutiny, and yet in nowise 
running into the opposite extreme of therapeutic nihilism, of mere negation 
and rejection. 

The notice we have thus taken of Oesterlen's work, brief as it is, will suffice 
to explain why it was, that during our sojourn in Europe, we have heard ex- 
pressed by competent judges, English, French, Russian, and German, but one 
opinion, and that the most favourable as to the merits of his Manual of Materia 
Medica and Therapeutics, an opinion corroborated by many German reviewers 
of the recent edition. It is also for this reason that we have felt ourselves in- 
duced to commend the work so highly to the attention of physicians, and to 
students of medicine at home. J. C. T. 



Art. XX. — New Remedies; with Formulce for their Preparation and Adminis- 
tration. By Robley Dunglison, M. D., Professor of the Institutes of Medi- 
cine, etc. in the Jefferson Medical College. Seventh edition. Philadelphia : 
Blanchard & Lea, 1856. 8vo. pp. 769. 

Although the New Remedies of Prof. Dunglison has been before the medical 
public for a long time, and therefore its general scope and character are well 
understood, yet the announcement of a new and seventh edition not only war- 
rants, but seems to require a brief notice ; more especially, as it has not been 
particularly described in this journal for a few years past. 

The remedial means, which are introduced into this edition for the first time, 
either from their recent discovery, or from new applications of old remedies, 
are twenty-eight in number ; some of them being of a very important character. 

Among others, we notice the chloride of bromine ; of which, the mode of 
preparing and the manner of using are described. This is the article employed 
by Dr. Landolfi, Surgeon of the Sicilian Army, in the treatment of cancer, and, 
as it is affirmed, with an unusual amount of success. His experiments are now 
attracting considerable attention in Europe. 

Santonin, the active principle of the European wormseed — semen contra — 
obtained from the various species of artemisia, is another of the articles newly 
introduced. This is now manufactured in Philadelphia, and the experiments 
made with it here coincide with those given in the work; namely, that it is 
peculiarly destructive to the long round worm. Its comparative tastelessness 
and small dose afford great advantages over the ordinary vermifuges. 

In the article on Cauterization and Catheterism of the Larynx and Trachea, 



218 



Bibliographical Notices. 



[July 



is to be found a resume of our present knowledge on this subject. The instru- 
ments employed, the mode of introducing, the solutions for medication, and 
the diseases, in which the supposed introduction has been tried, are noticed in 
detail. The author says, "There can be no doubt, that injections can be thrown 
into the bronchial tubes ; but it is difficult to suppose, that they can often 
reach tuberculous excavations in such quantity as to exert any direct action on 
the diseased surface. In many cases of bronchitis, however, they may prove 
beneficial." 

Quinidia, the new alkaloid obtained from Peruvian bark, or rather from the 
cheaper barks of the northern coast, is described ; and the experiments to 
determine its therapeutical value are succinctly referred to, which prove it to 
be an efficient substitute for the sulphate of quinia. The other remedies, used 
for the same purpose and now introduced for the first time, are Cedron seeds, 
Cinchonicine, and Apiol. 

The latter is a yellow, oily liquid, obtained from the common parsley, and is 
given in the dose of fifteen grains. "In the intermittents of Europe, apiol 
has succeeded in 86 cases out of 100. It has not been so fortunate in the 
fevers of hot countries: and MM. Joret and Homolle conclude, as the result of 
all observations, that it cannot be employed with the same advantage as the 
sulphate of quinia, in the intermittents of torrid regions ; but may very well 
be substituted for it in those of Europe." 

From the mineral kingdom, the metals — cerium, nickel, and tellurium, and 
the salts — chloride of iron, chloride of sodium, hyposulphite of soda and silver, 
iodide of sodium, permanganate of potassa, phosphate of lime, and the saccha- 
rine carbonate of iron and manganese ; together with caffein, carbazotic acid, 
cod-liver olein, Eau de Pagliari, galvanic cautery, hydriodic ether, pumpkin 
seeds, rennet, and traumaticine, are introduced either as " new remedies," or 
as old articles with new uses. 

The foregoing, however, does not convey a correct idea of the additions in 
the present volume, for a careful comparison of the leading and more important 
articles of the previous edition, shows that much care and attention have been 
bestowed upon their history. So that a full and fair exhibit of the present 
knowledge of the profession of their therapeutical properties is given. 

We might allude to aconitia, atropia, extract of hemp, cinchonia, colchicum, 
&c. &c, but it is unnecessary to enter into further detail. On the subject of 
anaesthetics, much valuable information is to be found in the articles on con- 
gelation, chloroform, and ether. 

There is one feature in this work which is particularly valuable, as the reme- 
dies it treats of are new either in introduction or in application. It is the 
precise reference for the asserted facts, to the authors and works by whom they 
are announced and from which they are taken. So that the student can refer 
to the original sources for more ample illustration. 

Another equally valuable feature is the subscription of formulae to most of 
the articles, for the administration of the remedies described. 

Upon the whole, therefore, we are disposed to consider this edition as not 
only sustaining the high reputation of the work which has carried it through 
six previous ones, but as being entitled to the favourable consideration of the 
profession as a faithful summary of the leading facts known, whether it be in 
the modes of preparation, the manner of using, or the effects of new remedies. 

, R. P. T. 



Art. XXI.— The Principles of Surgery. By J ames Miller, F. R. S. E., F. R. C. 
S. E., Professor of Surgery in the University of Edinburgh, &c. &c. &c. 
Fourth American, from the third and revised English edition. Illustrated 
by two hundred engravings on wood. Philadelphia: Blanchard &Lea, 1856. 
8vo. pp. 696. 

The publication of three Edinburgh and four Philadelphia editions, within 
not more than twelve years, decidedly indicates the high standing and sus- 



1856.] Wilson, Dissector's Manual of Surgical Anatomy. 219 



tained popularity of Professor Miller's treatise. Our readers are doubtless 
familiar with its merits as a favourite text-book. These are so generally known 
and have been already so repeatedly pointed out in previous notices, that we 
need scarcely do more on this occasion than announce the new edition. 

On account of the absence in Europe of Dr. Sargent, the present volume has 
been passed through the press without his editorial supervision. The aim of the 
publishers, as the advertisement informs us, has been " to render the work an 
exact transcript of the author's last and revised edition/ 7 in which such use 
had been made of the American annotations as the Professor himself had 
deemed advisable. In this desirable object we think the publishers have very 
happily succeeded. The result is certainly a book as handsome as their former 
issue, and one of more convenient dimensions, although amply furnished with 
useful matter, and bearing evidence of the usual progress in proportion to its 
date. 

We have looked it over with particular attention, and have compared its • 
pages, throughout, with those of its immediate predecessor in this country. 
Our examination has satisfied us that it has been carefully revised by its accom- 
plished author, and that, notwithstanding considerable accessions to the old 
contents, he has so managed by condensation and alteration as to reduce rather 
than augment the size of the whole. Much space has been gained for instance 
in the article on ansesthetics, in which a few brief paragraphs have been advan- 
tageously substituted for the long appendix on chloroform which formed an 
unduly prominent feature of the last edition. The additions are so incorpo- 
rated into the context of the different chapters as to make no change in the 
good order and precision of arrangement and fluency of style which have 
always characterized the work. Although introduced with marked discrimina- 
tion, they are yet sufficiently full to justify the long-established reputation of 
the author as a conscientious teacher of the actual state of surgical pathology 
and therapeutics; while they show him to be eminently free from the tendency 
to beguile the student with displays of reading or ingenious speculations in 
regard to unsettled questions or points of minor practical importance. 

On these accounts, especially, apart from the well known elegance and 
clearness of language, as well as comprehensive range of topics and elevated 
scientific tone of Professor Miller's treatise, we are glad to believe that 
its high position as one of the acknowleged exemplars of the Principles of 
Surgery — perhaps the best of its class — is abundantly maintained. We 
heartily commend it to the attention of pupils and practitioners as a valuable 
elementary preceptor. They may safely resort to it and, within the limits of 
a text-book, depend upon it as a reliable monitor and guide in their earlier 
studies ; while they will be apt to find it, along with works of greater compass 
and pretension, no mean instructor in any stage of a professional career. 

E. II. 



Art. XXII. — The Dissector's Manual of Practical and Surgical Anatomy. By 
Erasmus Wilson, F. R. S., author of "A System of Human Anatomy," &c. 
Third American, from the last revised London edition. Illustrated with one 
hundred and fifty-four wood engravings. Edited by William Hunt, M. D., 
Demonstrator of Anatomy in the University of Pennsylvania. Philadelphia : 
Blanchard & Lea. 

We have here the third American edition of this useful and popular work. 
Not claiming to be a complete "System of Human Anatomy," but a manual 
for dissectors; it will, we think, be found fully to meet the wants of those for 
whom it is intended, while its convenient size and arrangement will make it 
of more practical value in the dissecting-room than a more elaborate work 
could be. 

The edition before us, "besides being much enlarged and modified," has 
evidently been prepared with care ; and it would seem to have been the aim of 



220 



Bibliographical Notices. 



[July 



the editor rather to correct inaccuracies which had escaped observation in former 
editions than to add new matter of his own. Where additions have been made, 
they are of practical value and deserving the student'? attention; thus, on page 
29, he writes: — 

" The attention of the dissector should also be directed to some general facts 
in regard to the position of certain structures and their relative importance in 
the economy. Thus, he should remember that the great bloodvessels are placed 
upon the line of flexion, and as near as possible towards the inner side, and 
that this line includes all of the anterior aspect of the body with the exception 
of the legs. By this arrangement these essential parts are most effectually pro- 
tected from injury, and least exposed to disturbance from the movements of 
the body. He should also not lose sight of the ordinary laws of physics and 
mechanics, in his study of the human frame, for by an intelligent application 
of these, he will frequently be enabled to comprehend and give a purpose to a 
part (as of a muscle, for example) even before he has an exact idea of its posi- 
tion and relations. * * * When the subject is injected with chloride of 
zinc, a plan generally adopted in this country, care should be taken not to 
remove too much of the integument at once, as the parts when exposed will dry 
and become hardened very rapidly,'"' &c. 

We scarcely need add our belief that the reputation acquired by former edi- 
tions will be fully sustained by this. 



Art. XXIII. — Atlas of Cutaneous Diseases. By J. Moore Neligan, M. D., 
Edin., M.R.I. A., &c. &c. Philadelphia: Blanchard & Lea, 1856. 4to. 
PL XVI. 

The object of the author in the publication of thi3 book of Plates, " is to 
supply the student and junior practitioner with a work moderate in size, and 
cheap in price, which can be readily referred to in the study of what is admit- 
tedly an obscure class of diseases;" and he has " endeavoured to combine faith- 
fulness in representation with accuracy of finish, without which it could not 
prove a faithful guide." 

It is entirely beyond the power of language to convey, in many cases, accu- 
rate ideas of external characters, and hence the difficulty of learning to dis- 
criminate the various diseases of the skin, is insurmountable without the 
opportunity of studying them in a hospital appropriated to their treatment, 
or by the aid of accurate representations. 

The latter have been supplied by Dr. Neligan, and we can safely recommend 
his Atlas to students, and especially to country practitioners, as affording them 
a safe and reliable guide in the diagnosis of an obscure and important class of 
diseases. The American edition possesses all the accuracy of the original, 
and, in point of artistic execution, is very superior. 



1856.] 



221 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. On the Animal Starch and Cellulose Question. — Virchow (Archiv., vol. 
III. heft. 1) has given the results of further investigations on this subject. He 
divides the substance into true and false corpora amylacea, relying on the 
reaction of iodine and sulphuric acid, and on the fact that the true corpora 
amylacea are not soluble in hot alcohol, ether, &c, and are destroyed by con- 
centrated acids and alkalies. Among the false bodies he classes : 1st. The 
brain-sand, probably the same which Busk described as being found in the 
corpus callosum, and which was coloured externally of a yellowish-red hue by 
iodine. 2d. Various gelatinous and albuminous grains spoken of as colloid- 
grains in certain tumours. 3d. The concentric epidermal globules often found 
in the thymus gland and cancroid tumours. 4th. The bodies found in coagu- 
lated blood described by Gulliver, Gerber, and Hassall. 5th. The medullary 
matter described by Virchow himself on a previous occasion. 6th. The leucine 
grains obtained from extract of milk. 

According to Virchow the following are the places wherein true amyloid 
degeneration is certainly to be found. They are — 1st. The nervous system. 
Besides the fore-mentioned parts, the spinal ligament of the cochlea, and many 
parts of atrophied brain and spinal marrow, show it. He had found it in the 
gelatinous and cellular softening of these structures, and he mentions its dis- 
covery by Busk in one case almost throughout the brain and the choroid plexus ; 
by Willigk in cicatrices of brain; and by Kokitansky in atrophied parts of brain 
and other structures. 2d. In the spleen. In the follicular cells and pulp, the 
thickened walls of arteries, especially circular fibres, and in the trabeculse. 
3d. In the liver. In the waxy degeneration, chiefly in the cells, but also in 
intervening tissue. 4th. In the kidneys, which are pre-eminently the subject 
of the degeneration. The Malpighian bodies and the arteries leading to them 
become first affected ; then the areolar tissue in the neighbourhood of urinary 
tubes of papillse ; and then the other parts. Virchow says, that in most organs 
where they are found we have undoubted changes of the tissue elements, and 
that probably there is a " conversion into vegetable matter." 

These starch bodies, chemically as well as morphologically, are very allied 
to starch bodies of plants. Busk says he has often seen in the smaller ones a 
dark cross by polarized light, whose arms intersect each other in the middle of 
the grains at an angle of 45°, the majority only showing a simple dark line. 
It seems necessary to guard against error by the remembrance that in several 
false amylaceous bodies a yellowish-red colour, called by Meckel iodine-red, is 
found by addition of iodine ; and this is the case also with all blood-holding 
parts. The later addition of sulphuric acid will be requisite to determine the 
presence of true amyloid substance. This yellow or iodine-red appearance is 
No. LXIIL— July 1856. 15 



222 



Progress of the Medical Sciences. 



[July 



compared by Busk to the appearance produced in unripe cellulose, such as is 
wont to occur in the lower plants. But in plants we have quantities of cellu- 
lose mixed with gelatinous substances, so that in the treatment with iodine 
and sulphuric acid we have all sorts of immature colours, indicating a mixture 
of blue and red, brown and yellow. Such a play of colours takes place in the 
spleen, especially in the amyloid substance from the pulp and follicles, but in 
no case does the blue or blue-red come forward with such clearness as in 
the Malpighian bodies and afferent arteries of the parenchyma of the kidney. 
Our author concludes that sooner or later the albuminous substance of the 
tissues disappears, and is replaced by amyloid substance. In those instances 
where the substance differed still more from starch proper it becomes more 
like cellulose proper ; and the organs affected show that peculiar look called 
waxy or lardaceous. The same idea is acknowledged by Virchow to have 
arisen also at Edinburgh independently of himself. Generally the indurated 
organs are enlarged, leaving no doubt of the deposit of new matter. The co- 
existence of the same alteration in the spleen, liver, and kidneys leads natu- 
rally to the recognition of a common cause, a constitutional disturbance. 

Since the above was written by Virchow in the Archiv, he has made another 
communication on the same subject ; but before speaking of this, we will men- 
tion a communication made 1 by Mr. Carter, entitled the "Extensive Diffusion 
and Frequency of Starch Corpuscles in the Tissues of the Human Body." In 
this, it will be seen, a different view is maintained on certain points. This 
observer saw the starch bodies in a tumour involving the optic nerve, and also 
the pineal gland of man and sheep; and, since then, made extensive experi- 
ments, examining in succession thirteen human bodies out of the clinical wards 
of Professor Bennett, of Edinburgh. He met with two kinds of starch, one 
resembling wheat, the other potato starch ; and he found them in the liver, 
spleen, kidneys, brain, pancreas, mesenteric glands, suprarenal capsules, Pac- 
chionian bodies, mesentery, lungs, ovaries, scrofulous matter, pus, urine, epi- 
dermis, blood, and other places, in organs as well healthy as diseased. In one 
case he found them around an apoplectic clot, but could not find them in any 
other part of the brain. In a case of diabetes, the other organs presented an 
unusual amount, but the liver was free from any. He never seems to have 
found them in the muscular structure of the heart. In the sheep, oxen, and 
lower animals, they were found in the same indiscriminate way ; and the 
author says that they have hitherto been mistaken for fatty oil globules, to 
which, from form and refractile powers, they have much resemblance. He 
considers them as of physiological, not of pathological interest, being ordinary 
constituents of the body, and, as he calls them, "the thermogenic magazines," 
analogous to fatty substance, and capable, possibly, of conversion into grape 
sugar and carbonic acid, or into the lactic acid of the gastric juice. 

In the second paper by Virchow {Archiv, p. 364), to which we have alluded, 
the author thinks he has made considerable advances on the subject. In all 
the cases in which he found the cellulose, chronic and extensive disease of the 
osseous system existed ; and he thinks these diseases exercise a determinate 
influence on the production of the waxy " degeneration" — the disease, espe- 
cially caries and necrosis, inducing a deficit of nutrition and cachexy, thus 
robbing the spleen, kidneys, &c, of their natural elements, and disposing them 
to take on the degeneration. He has never met with the amyloid substance in 
the bones, but has so done in the cartilage of the joints of an old person with 
senile arthritis. — Brit, and For. Med.-Chirurg. Rev., April, 1&56. 

2. The Earthy Phosphates in Urine. — Neubauer, who has conducted a very 
laborious and precise investigation respecting the quantities of earthy phos- 
phates present in urine under various conditions, has arrived at the following 
results : — 

1. In the normal state, a growing man of 20-25 years old, partaking of a 
mixed diet, voids in twenty-four hours, as the mean of fifty-two observations, 
from .9441 to 1.012 grammes of earthy phosphates. The maximum voided in 



1 Edinburgh Medical Journal. August, 1855. 



1856.] 



Materia Medica and Pharmacy. 



223 



twenty-four hours amounted, upon an average, from 1.138 to 1.263 grm., and 
once only to 1.554 grm. The minimum amounted, upon an average, to .8 
grm., and once only to .328 grm. 

2. The phosphate of lime, as a mean of fifty-two observations, amounted to 
from .31 to .37 grm. The mean maximum was from .39 to .37 grm. ; the mean 
minimum was nearly constant, .25 grm., and only once amounted to .15 grm. 

3. The phosphate of magnesia amounted to .64 grm., as the mean of fifty- 
two observations. The maximum was, upon an average, .77 grm. ; only once 
were .938 grm. voided. The mean minimum amounted to .5 grm., but once 
sank to .178 grm. 

4. In the normal condition, upon an average, three equivalents of 2 Mg 0, 
P 5 were voided to one equivalent of 3 Ca 0, P 5 . As a mean the entire 
phosphates consisted of 67 per cent, of phosphate of lime, and 33 per cent, of 
phosphate of magnesia in 100 parts. 

5. Salts of lime, when taken, pass over, either not at all or in very small 
quantity, into the urine. The entire quantity of normal phosphates passing 
into the urine undergoes, in consequence, no important increase. 

6. In disease, the absolute quantity of earthy phosphates, as well as the 
relative proportion between the lime and magnesia phosphates, appear to de- 
part considerably from the normal condition. — Lancet, April 26, 1856. 



MATERIA MEDICA AND PHARMACY. 

3. Quinated Cod-Liver Oil. By M. Donovan. — A preparation of cod-liver oil, 
called oleum aselli cum quina, has been lately introduced into medical practice, 
and is favourably noticed by some practitioners. It is probable that the tonic 
effects of quinine, conjoined with the restorative powers of the oil, may afford 
a combination of greater efficacy than is possessed by either separately. To 
many persons, the mawkish taste of the oil modified into the decided bitter of 
the quinine is an improvement. I have been informed that the combination of 
sulphate of quinine with cod-liver oil is effected by exposing them in a state of 
mixture to a certain temperature : if the heat be too high or too low, the com- 
bination, it is said, will either not take place or it will be subverted. I have 
made some trials with very unsatisfactory results, the quantity of sulphate 
which dissolved being very small, as might be expected from the character of 
sulphates in general. 

Aware that the alkaline basis of sulphate of quinine possesses some of the 
properties of a resin, it seemed probable that it might dissolve in oil; and, on 
making the experiment, I found that this is actually the case. 

The alkaloid quinine is known to possess little efficacy as a medicine on 
account of its insolubility in aqueous liquids ; hence, it is always administered 
in the state of acidulated disulphate, or, in other words, in the state of sul- 
phate. Oil, by rendering quinine soluble, develops the medicinal virtues of 
that alkaloid, and thus, for every useful purpose, acts the part of sulphuric acid. 

A few trials convinced me that quinine may be dissolved in cold cod-liver 
oil in even greater ratio than is ever necessary for the purposes of the physi- 
cian. A solution of eight grains to the ounce is intensely and persistently 
bitter. When the mixture is first made, a very disagreeable and peculiar smell 
is developed; but by exposure to the air for an hour or two, or better by filter- 
ing, the smell exhales and is dissipated. The colour of the oil is deepened by 
the combination. 

This compound, which may be briefly named oleum aselli quinatum, has this 
advantage, that two active medicines, of coinciding effects, may be thus admi- 
nistered at one dose. To some, it is a severe trial to swallow either of them; 
and to such persons it would be a relief, instead of taking two separate disa- 
greeable doses at different times, to swallow both at once, and have done with 
them. 



224 



Progress of the Medical Sciences. 



[July 



There are constitutions which will, not tolerate the free exhibition of cod- 
liver oil, and patients of this class are precluded from availing themselves of 
advantages -which might have been of the utmost value to them. Perhaps the 
quinated oil would agree better with such stomachs. — Dublin Medical Press, 
March 26, 1856. 



MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

MEDICINE. 

4. Asphyxia, its Rationale and its Remedy. — By Marshall Hall, M. D. 
The term Asphyxia, which ought to be exchanged for apncea, designates that 
condition of the animal system which results from the suspension of respira- 
tion. 

Respiration involves two processes — the inhalation of oxygen, and the exha- 
lation of carbonic acid. 

Hhe remedy for the suspension of respiration is, on every principle of com- 
mon sense, the restoration of respiration. This view might be considered, 
irrespective of physiological inquiry and proof, as self-evident; but that proof 
is amply supplied by physiology. 

Of the two functions suspended, it is certain, from physiological inquiry, 
that the retention of the carbonic acid is by far the more fatal, and that, in a 
word, asphyxia is the result of carbonic acid retained in the blood, which be- 
comes, in its excess, a blood-poison. 

If this view be correct, it is evident that restored respiration is to the blood- 
poison in asphyxia what the stomach-pump is to poison in the stomach ; and 
that it is the special remedy, the sine qua non, in asphyxia. 

But this blood-poison is formed with a rapidity proportionate to the circula- 
tion, which is, in its turn, proportionate to the temperature. To elevate the 
temperature, or to accelerate the circulation, without having first secured the 
return of respiration, is therefore not to save, but in reality to destroy life! 

Now, let me draw my reader's attention to the Rules for treating asphyxia, 
proposed and practised by the Royal Humane Society. They are as follow: — 

" 1. Convey the body carefully, with the head and shoulders supported in a 
raised position, to the nearest house. 

"2. Strip the body, and rub it dry; then wrap it in hot blankets, and then 
place it in a warm bed in a warm chamber free from smoke. 

"3. Wipe and cleanse the mouth and nostrils. 

" 4. In order to restore the natural warmth of the body : — 

Move a heated covered warming-pan over the back and spine. 
Put bladders or bottles of hot water, or heated bricks, to the pit of the 
stomach, the arm-pits, between the thighs, and to the soles of the feet. 
Foment the body with hot flannels. 

Rub the body briskly with the hand ; do not, however, suspend the use 
of the other means at the same time ; but, if possible, immerse the 
body in a warm bath at blood heat, or 100 deg. of the thermometer, as 
this is preferable to the other means for restoring warmth. 
"5. Volatile salts or hartshorn to be passed occasionally to and fro under 
the nostrils. 

"6. No more persons to be admitted into the room than is absolutely 
necessary." . . 

My first remark on these rules for treating asphyxia is, that "to convey the 
body to the nearest house," is doubly wrong. In the first place, the loss of time 
necessary for this purpose is — loss of life! on the contrary, not a moment 
should be lost; the patient should be treated instantly, on the spot, therefore. 
In the second place, except in very inclement weather, the exposure of the face 
and thorax to the breeze is an important auxiliary to the special treatment of 
asphyxia. 

But most of all, the various modes of restoring the temperature of the pa- 



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tient, the warm-bath especially, are objectionable, or more than objectionable; 
they are at once inappropriate, unphysiological, and deleterious. 

If there be a fact well established in physiology, it is that an animal bears 
the suspension of respiration in proportion, not to the warmth, but, within 
physiological limits, to the lowness of the temperature, the lower limit being 
about 60° Fahr. A warm-bath of 100° Fahr. must be injurious. 

All other modes of inducing warmth are also injurious, if they divert the 
attention from the one remedy in asphyxia — artificial respiration, — or otherwise 
interfere with the measures to be adopted with the object of restoring this lost 
function. 

Such, then, are the views which the scientific physician must take in regard 
to the late rules for treating asphyxia promulgated by the Royal Humane 
Society. 

I now proceed to state the measures by which those rules must be replaced. 

I revert to a proposition already made : as asphyxia is the result of sus- 
pended respiration, the one remedy for the condition so induced is, self-evi- 
dently and experimentally, the restoration of respiration. 

But there is an impediment to artificial respiration never before pointed out. 
It is the obstruction of the glottis or the entrance into the windpipe, in the 
supine position, by the tongue falling backwards, and carrying with it the 
epiglottis — an event which can only be effectually remedied by adopting the 
prone position. 

In this position the tongue falls forward, drawing with it the epiglottis, and 
leaving the ingress into the windpipe free. 

But even when the way is patent, there remains the question, how is respi- 
ration to be effected ? The syringe or the bellows may not be at hand, and if 
they were, the violence used by them is apt to tear the delicate tissue of the 
lungs. The mode proposed by Leroy, of compressing the thorax by means of 
a bandage, and allowing its expansion by the resilience of the costal cartilages, 
is proved by experiment to be futile, chiefly, no doubt, from its being attempted 
in the supine position, with the glottis obstructed. 

The one effectual mode of proceeding is this : let the patient be placed in 
the prone position, the head and neck being preserved in their proper place. 
The tongue will fall forward, and leave the entrance into the windpipe free. 
But this is not all, the thorax and abdomen will be compressed with a force 
equal to the weight of the body, and expiration will take place. Let the body 
be now turned gently on the side (through rather more than the quarter of a 
circle), and the pressure on the thorax and abdomen will be removed, and re- 
spiration — effectual inspiration — will take place! The expiration and inspira- 
tion are augmented by timeously applying and removing alternately pressure 
on the spine and ribs. 

Nothing can be more beautiful than this life-giving — (if life can be given) — 
this breathing process. 

In one series of experiments, twenty cubic inches of air were expelled on 
placing a corpse in the prone position, and ten cubic inches more by making 
pressure on the thorax and ribs, the same quantities being mhaled on removing 
that pressure, and on rotating the body on its side. But I must give the ex- 
periments in detail : — 

A subject was laid on the table, and pressure made on the thorax and ribs, 
so as to imitate the procedure of Leroy. There was no result ; a little gurgling 
was heard in the throat, but no inspiration followed. The tongue had fallen 
backwards, and closed the glottis or aperture into the windpipe ! All inspira- 
tion was prevented. 

Another subject was placed in the prone position. The tongue having fallen 
forwards, and the glottis being free, there was the expiration of twenty cubic 
inches of air, a quantity increased by ten cubic inches more on making pres- 
sure along the posterior part of the thorax and on the ribs. On removing this 
pressure, and turning the body through a quarter of a circle or rather more, 
on the side, the whole of the thirty cubic inches of air were inspired ! 

These manoeuvres being repeated, ample respiration was performed ! 



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Nay, there may be a question whether such considerable acts of respiration 
may not be too much. 

It is to be observed, however, that, in this mode of artificial respiration, no 
force is used ; the lung therefore is not injured; and that, as the air in the 
trachea and bronchial tubes undergoes little or no change in quantity, the 
whole inspired air passes into the air-cells, where the function of respiration is 
alone performed. 

It deserves to be noticed, that in the beginning of this experiment in the 
prone position, the head had been allowed to hang over the edge of the table : 
all respiration was frustrated ! Such is the importance of position. 

Reserving the full exposition of this method of postural respiration, this 
theseopnoea (from 6s6^, position), for another occasion, I will conclude by reduc- 
ing these views into the simplest Rules for the treatment of asphyxia. 

New Rules for the Treatment of Asphyxia. 

I. Send with all speed for medical aid, for articles of clothing, blankets, &c. 

II. Treat the patient on the spot, in the open air, exposing the face and 
chest freely to the breeze, except in too cold weather. 

I. To excite Respiration, 

III. Place the patient gently on the face (to allow any fluids to flow from 
the mouth). 

IV. Then raise the patient into the sitting posture, and endeavour to excite 
respiration, 

1. By snuff, hartshorn, &c, applied to the nostrils; 

2. By irritating the throat by a feather or the finger ; 

3. By dashing hot and cold water alternately on the face and chest. 
If there be no success, lose no time, but 

II. To imitate Respiration, 

V. Replace the patient on his face, his arms under his head, that the tongue 
may fall forward, and leave the entrance into the windpipe free, and that any 
fluids may flow out of the mouth; then 

1. Turn the body gradually but completely on the side, and a little more, and 
then again on the face, alternately (to induce inspiration and expiration); 

2. When replaced, apply pressure along the back and ribs, and then remove 
it (to induce further expiration and inspiration), and proceed as before; 

3. Let these measures be repeated gently, deliberately, but efficiently and 
perseveringly, sixteen times in the minute only ; 

III. To induce Circulation and Warmth, 

1. Continuing these measures, rub all the limbs and the trunk upwards with 
the warm hands, making firm press ure energetically; 

2. Replace the wet clothes by such other covering, &c, as can be procured. 

VI. Omit the warm-bath until respiration be re-established. 

To recapitulate, I observe that — 

1. If there be one fact more self-evident than another, it is that artificial res- 
piration is the sine qua non in the treatment of asphyxia, apnoea, or suspended 
respiration. 

2. If there be one fact more established in physiology than -another, it is that 
within just limits, a low temperature conduces to the protraction of life, in 
cases of suspended respiration, and that a more elevated temperature destroys 
life. This is the result of the admirable, the incomparable, work of Edwards. 

3. Now the only mode of inducing efficient respiration artificially, at all times 
and under all circumstances, by the hands alone, is that of the postural 
manoeuvres described in this paper. 

This measure must be adopted. 

4. The next measure is, I have stated, to restore the circulation and warmth 
by means of pressure firmly and simultaneously applied in the course of the 
veins, therefore upwards. 



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5. And the measure not to he adopted, because it tends to extinguish life, is 
the warm bath, icithout artificial respiration. 
This measure must be relinquished. 

These conclusions are at once the conclusions of common sense and of phy- 
siological experiment. On these views human life may, nay, must, sometimes 
depend. — Lancet, April 12, 1856. 

5. On Jugular Venesection in Asphyxia, Anatomically and. Experimentally 
Considered. — A paper on this subject was read before the Medico-Chirurgical 
Society of Edinburgh (March 19th, 1856), by Dr. Struthers. The object of 
the paper, which was illustrated by preparations and drawings of the valves in 
the cervical veins of the human subject, was to ascertain whether distension of 
the right side of the heart could be relieved by opening the external jugular 
vein in the human subject. The experiments of Drs. John Reid, Cormack, and 
Lonsdale, had satisfactorily shown that, in the lower animals (dogs, cats, and 
rabbits), the right side of the heart could be thus disgorged so as to restore its 
action, which had been arrested by a simple mechanical cause, over distension. 
He considered that the indication of restoring the heart's action by jugular re- 
gurgitation, had not received that attention which Dr. Reid's suggestive paper 
demanded for it. Dr. Struthers described the anatomy of valves which he had 
found in the cervical veins, as well as those usually alluded to as present in 
the external jugular. A pair of valves at or within the mouth of the internal 
jugular vein ; a pair in the subclavian vein immediately external to the point 
of union with the external jugular ; a pair at or within the mouth of the exter- 
nal jugular ; a second pair in the course of the external jugular, at the upper 
end of its sinus, or large portion, about \h inch above the clavicle, and various 
lesser valves at the mouths or within the tributaries of the external jugular. 
The varieties, and relative position of the two portions of each pair of valves 
was described, as he had found them in numerous careful examinations. With 
the view of ascertaining whether regurgitation could take place notwithstand- 
ing these valves, Dr. S. performed a series of experiments on the dead subject. 
A pipe was fixed in the femoral vein, and tepid water thrown freely upwards. 
The general result was, that the external and other jugular veins very soon be- 
came distended, and that when the lancet opening was made, at about an inch 
above the clavicle, the fluid regurgitated freely. At first a jet came, emptying 
the distended sinus, and then it continued to flow, never in a jet, but in an 
active stream across the neck, escaping by the wound with a wriggling motion, 
evidently due to the obstruction offered by the valve which it had overcome. 
Care was taken to ascertain that the fluid came by regurgitation, not from 
above ; but, if allowed, it also came freely from above, having ascended by the 
internal jugular. The introduction of a probe so as to hold aside the guardian 
valve of the external jugular did not much accelerate the regurgitating flow. 
When the catheter was introduced, however, the fluid came very freely by it — 
as freely as from a distended bladder. It is easy to introduce a common male 
catheter to the vena cava or right auricle, by directing it backwards and in- 
wards, as well as downwards, from the point of venesection. But as soon as 
the catheter has entered the subclavian vein, the fluid comes as freely as when 
it is pushed farther. As soon as the point of the catheter is withdrawn into the 
external jugular, the fluid ceases to come by it. In one subject the fluid could 
not be made to regurgitate. This was at the time attributed to the circum- 
stance that the cranium had been opened for the removal of the brain, the fluid 
pouring out by the cranial sinuses : but, on dissection, two pairs of valves were 
found in the external jugular below the lancet opening, besides the pair above 
it, as usual. Regurgitation seems to be prevented by two pairs of valves, 
though one pair may be overcome. In these experiments the veins of the arm 
did not become distended, and no regurgitation took place from a lancet-open- 
ing in the axillary vein, although afterwards it was seen that only two pair of 
valves had stood in the way, between the heart and the opening. By " pair," 
Dr. S. meant the two separate portions which act together as one valve. He 
(Dr. S.) drew the following conclusions: 1. No venesection can be of any use 
in asphyxia, except in the neck, on the principle of regurgitation ; which, how- 



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ever, may also relieve congestion of the head. 2. That, besides warmth and 
friction, and (the most simple and effectual of all means) continued artificial 
respiration by alternate compression and relaxation of the sides of the chest, 
jugular venesection should be tried. 3. With reference to Dr. M. Hall's re- 
cent recommendation of the prone position, to prevent the tongue falling back 
and closing the glottis, the question occurred — Does the tongue fall back, un- 
der passive circumstances, in the supine position ? Is not the closing of the 
superior glottis, under all circumstances, a muscular act — both the carrying 
down and back of the tongue and epiglottis, and the lifting upwards and 
forwards of the larynx? The mouth, however, should be cleared of frothy 
mucus. 4. That to obviate the evident risk of entrance of air into the veins, 
the wound should be closed as soon as regurgitation is about to cease, and 
artificial respiration be then commenced; the jugular venesection having been 
performed as early as possible. — Edinburgh Medical Journal, May, 1856. 

6. Syncope Senilis, arising from Gastric Irritation. — Mr. John Higginbot- 
tom has given the name of syncope senilis to an affection common, he says, to 
all ages, but which occurs in a more aggravated form in infancy and old age. 
The S3 7 mptom of syncope is not very apparent in the former period of life, but 
is so in old age, and is the first symptom requiring prompt attention, for if 
remedies are neglected, convulsions and death follow. 

"It is," Mr. H. observes, "about thirty years since I first noticed particu- 
larly the syncope senilis. The subject was about seventy years of age. I 
thought at that time it was a precursor of an attack of apoplexy, the patient 
having had a slight paralysis when about twenty-three years of age, which 
affected him slightly through life. I was glad to find, on his recovery, that 
there was no increase of his paralytic symptoms. Since that time, I have often 
observed the same syncope, unattended by any permanent ill effects. 

" My patients have been from sixty-eight to eighty-six years of age ; the 
youngest sixty-eight, the oldest eighty- six. I am not aware that they have 
laboured under any organic disease whatever ; but we all know, that at an ad- 
vanced age the brain and heart, the nervous and vascular system, are fre- 
quently more inactive, and in an impaired condition. 

"In the cases I have attended of syncope senilis, gastric irritation appears to 
have been the sole cause of the attack. At that advanced age, mastication of 
the food is very imperfectly or not at all performed, for want of teeth ; solid 
animal food has been eaten when the stomach has been in an unfit state to 
assimilate it, usually after having had a longer walk than the patient has been 
accustomed to, or had more muscular exertion than usual, so as to produce 
fatigue, and sometimes after exposure to cold; all which tend to weaken the 
power of the stomach. On this account the food remains an indigestible mass 
in the stomach, and gives rise to gastric irritation, producing syncope and 
convulsion, which sometimes follows, often slight at first, but becoming more 
formidable, or even fatal, if proper remedies are not promptly used. 

" I was called to a patient about three o'clock in the morning, his wife having 
been awoke by his hard breathing and noise in his throat. She found her 
husband was in a fit. I was directly sent for. When I arrived he had par- 
tially recovered, but very soon after he had a second fit, which had the appear- 
ance of a slight attack of epilepsy, attended with convulsion, but had no bitten 
tongue, as is usual in severe attacks of epilepsy. As soon, as he was suffi- 
ciently recovered from the attack, so that he could swallow, I gave him half a 
drachm of the powder of ipecacuanha with fifteen grains of the bicarbonate of 
potass, which was followed by full vomiting ; he ejected lumps of solid beef, 
which appeared to have been swallowed, or rather bolted, without having been 
masticated at all ; one of the pieces, I observed, was about an inch long and 
three quarters of an inch in thickness. Although the food had been taken 
into the stomach about sixteen hours, the acute corners and edges of the beef 
appeared as if just cut with a sharp knife, not the least digested. No further 
remedy was required after the emetic, but attention to the bowels, which he 
reluctantly submitted to, saying he was quite well. 

"In a month afterwards he had another fit of a similar nature. He fell down 



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Medical Pathology and Therapeutics. 



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in a moment on the floor, and remained in the same state as in the former case 
for half an hour; the same remedies were resorted to as before, and he re- 
covered quickly. I expect the patient will have a return of the syncope, as he 
is very wilful, and will not attend to any means of prevention. This patient 
was the youngest, being sixty-eight years of age. Previous to the first fit he 
had been using much muscular exertion, still being active in business. 

" Another case is that of an old patient of eighty-six years, who at intervals of 
a few weeks had several similar attacks of syncope. After the last fit, attended 
with slight convulsion, I was induced to think it had been occasioned by taking 
solid food, which was swallowed after imperfect mastication ; on that account 
I forbade him the use of animal food altogether. This regimen he has now 
strictly adhered to for some months, except a few times having taken a small 
quantity of tripe. He has had no return of his fainting fit, a much longer 
time having now elapsed than the interval after which he had several of the 
previous attacks. I would make an observation here, as a contrast to the 
former case I have related in the younger man, that at a more advanced age 
the patient does not recover so quickly from the attack, but requires particular 
attention to the digestive organs for some days, with gentle aperients, and 
saline medicine in a state of effervescence. 

" It is not unusual for even young men to have similar attacks from indiges- 
tion, when sudden syncope for a short period comes on, recovery taking place 
in a few moments. The same attack at an advanced age, I presume, would be 
attended with aggravated symptoms, such as those I have witnessed. 

Mr. H. considers the last illness of the Duke of Wellington to have been 
syncope senilis, and believes with Dr. M. Hall that if efficient vomiting had 
been induced, the Duke's life might have been saved. 

Mr. H. says that he knows "no emetic equal in such a case to half a drachm 
of the powder of ipecacuanha, with the addition of ten or fifteen grains of the 
bicarbonate of potass, as it corrects any acidity in the stomach, and produces 
full vomiting both safely and quickly ; it has also the power of raising the 
system to its normal condition, without producing any unnatural excitement, 
and promotes the healthy secretions of the various organs of the body. The 
nausea and inefficient vomiting arising from natural efforts to empty the sto- 
mach, I have no doubt produces debility and exhaustion, when a full vomiting 
from ipecacuanha has the contrary effect. Should the first half-drachm of ipe- 
cacuanha not operate, a second such dose may be given with the greatest 
safety, it only having the effect of a more speedy operation. If vomiting still 
should not follow, the fauces might be irritated with a feather, to excite it. 
I have for the last forty years given ipecacuanha emetics with the same free- 
dom as I have purgatives, and never saw any bad result. 

"It might be thought by some individuals that abstaining from animal food 
at the period of old age might be attended with the loss of health and strength. 
I had an instance in a relation of my own family, who, at seventy years of 
age, quite abstained from animal food, and also from wine. After the lapse 
of ten years, when at the age of eighty, he was requested by his relatives to 
resume his animal food and wine, he excused himself from taking either of 
them by saying he did not want them, for he was very healthy, and in good 
spirits, although very thin in body. He lived till he was nearly ninety years 
of age. This old gentleman, I apprehend, would have been a likely subject 
for the syncope senilis had he been in the habit of taking solid animal food, 
which he could not masticate, and would most probably have shortened his 
days. 

" At an advanced age, when the physical powers of the body are declining, 
and second childhood approaching, and at that period when comparatively 
little exercise only can be taken, the body does not require the same solid food. 
Nature points out the use of milk and light farinaceous matter as an aliment, 
as being more natural, and adapted to that period of life ; such food alone is 
sufficient to keep the body in a healthy, cheerful, and happy state. It has 
been erroneously stated that "wine is the milk of old age;" I believe the truth 
is, that milk is the wine of old age, for both the first and second childhood, the 
most natural and the most nutritious. Dr. Erasmus Darwin used to say, 



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" Milk is white blood." The oldest individuals I have known, have lived prin- 
cipally upon milk diet. Second childhood may be treated much in the way as 
directed by the late Dr. James Hamilton, Professor of Midwifery in the Uni- 
versity of Edinburgh : " Plenty of milk, plenty of flannel, and plenty of sleep 
or rest." — Lancet, April 26, 1856. 

7. On Treatment of Fever by Large and Frequently Repeated Doses of Quinine. 
— Contradictory reports have been made by different practitioners as to the 
success attending Dr. Dundas's mode of employing quinine in the treatment 
of fever, and with a view of contributing to the establishment of the truth Dr. 
Thomas B. Peacock has reported [Med. Times and Gaz., Jan. 12 and 19, 1856) 
the results which he has obtained from the quinine treatment as employed in St. 
Thomas's Hospital, and compared the average mortality and duration of the 
cases in which it was administered, with the similar facts as to those in which 
the more ordinary treatment was had recourse to. 

" On referring," he states, " to the hospital records, I find that during the 
present year, from January to October inclusive, there were treated in St. 
Thomas's, 139 cases of fever of all kinds, excluding the cases entered as febri- 
cula and ephemera. Of the 139 cases, 20 were subjected to the quinine treat- 
ment. In one case, 4 grains of the drug were given every two hours ; in a 
second, 5 grains were exhibited three times daily; in a third, 5 grains were 
administered every three hours; in four others, 5 grains every four hours; in 
two, 6 grains every three and every six hours ; in two, 8 grains every four 
hours ; in two, 10 grains every two hours ; in three, 10 grains every six hours ; 
and in one, 15 grains every six hours. In three cases (one male and two 
females), the remedy was only given in doses of 2 grains three times daily. 
In six of the cases, the exhibition of the quinine was commenced on the day of 
the patient's admission into the hospital ; in eight, on the following day ; in 
one, on the third day ; and in one, on the fifth day from admission. In one 
case, in which the patient took fever in the hospital, the precise period of the 
disease at which the quinine treatment was commenced, is not stated, but it 
may be inferred not to have been later than the third or fourth day. In all the 
cases, stimulants and support were had recourse to, as required. Of the twenty 
patients, fifteen were males, and five females ; the respective proportions of the 
sexes being 75 and 25 per cent. 

" The mean age was in males, 24.1 ; the extremes, 17 and 35 
" females, 20; " 14 and 29 

" " both sexes, 23.4. 

"The mean period of admission was in males, 9 days. 

" • females, 10 " 
" both sexes, 9.1. 

" Deducting the three cases in which small doses only were given, the mor- 
tality was — 

In males, 2 ; in females, 1 ; or, 

In males 14.2 per cent. 

females 33.3 " 

both sexes 17.6 " 

" The mean period of residence of the cases cured, excluding those in which 
small doses only were given, and one case detained in hospital eighty-four 
days, from accidental circumstances, was — 

In males . . . . . . . 28.7 days. 

females 20.5 " 

both sexes 29 i( 

"During the same period of nine months there were, as before stated, 119 other 
cases of fever treated in the hospital. In some of these cases, little else was 
given than soda water, and suitable support and stimulus. In others, the treat- 
ment consisted in the exhibition of chlorate of potash, dissolved in water or 
decoction or infusion of bark, with or without hydrochloric acid, in doses of 8 



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Medical Pathology and Therapeutics. 



231 



or 10 grains, every two or three hours. In yet other cases, the sesquicarbonate 
of ammonia, in doses of 5 to 8 grains, was given in infusion of serpentary or 
decoction of bark at intervals of 2 to 4 hours ; this treatment being commenced 
either at an early period of the disease, or towards its termination. In both 
these sets of cases, diffusible stimulus and support were also given, according 
to the amount of prostration. 

"Of the 119 cases, 73 were males, and 46 were females, being respectively 
61.3 and 38.6 per cent. 

" The mean age of the patients was — 

In males, 24.5 ; extremes, 4 and 72 
females, 24 ; " 5 and 58 

both sexes, 24.4 
" The mean period of admission was — 

In males 10.4 days. 

females 9.5 " 

both sexes 10.2 " 

" The mortality was in males, 10 ; in females, 5 ; or, 

In males 13.6 per cent. 

females 10.8 " 

both sexes 12.6 " 

" The mean period of residence of the cases cured (deducting those detained 
in the hospital from accidental causes), was — 

In males 27.2 days. 

females 29.8 " 

both sexes ...... 28.1 " 

"It will be seen, on comparing these two series of observations, that they 
bear a very close general resemblance, as regards the circumstances which most 
materially affect the results of the treatment pursued ; as the age and sex of the 
patients, and the period of the disease at which they were admitted into the 
hospital ; indeed, in the last two particulars, the advantage was rather in favour 
of the cases treated by quinine. The two series may, therefore, be admitted as 
affording some test of the respective merits of the systems of treatment pursued ; 
and it will be seen, that in the quinine cases the rate of mortality is considerably 
higher, and the durations of residence longer, than in others. 

" It may, however, be objected that a calculation founded upon the respective 
duration of residence of the cases in hospital, does not afford a satisfactory 
standard of comparison, as being liable to be affected by accidental causes; and 
there can be no doubt of the truth of this remark. The period during which a 
patient is detained in bed, would, exceptional cases being omitted, afford more 
exact results ; but the comparison of the periods at which the patients are re- 
garded as free from fever, as adopted by Dr. Gee and Mr. Eddowes, or the 
period of convalescence, would be a still less satisfactory standard, because 
liable to greater variation from the views of different observers. In the calcu- 
lations above given, I have endeavoured to guard against incorrect results, by 
excluding all cases detained for a longer period than usual, from casual circum- 
stances. 

"It may also be contended, that the number of cases in which the quinine 
treatment was had recourse to, was so small, that the inferences deduced from 
them cannot be depended upon. Admitting the force of this objection, I have 
collected all the cases in which the quinine treatment was employed in the 
Hospital during the year 1854. These I find amount to twenty in number, of 
which twelve were males and eight females ; but two, one male and one female, 
took the remedy only in small doses. Deducting these, there remain eighteen 
cases in which the quinine was exhibited, in doses varying from 2 and 4 grains 
every four hours and three times daily, in boys of 8, 10, and 15 years of age, to 
5, 8, and 10 grains every two, four, six, and eight hours, in adults. The remedy 
was commenced on the day of the patient's admission into the hospital in seven 
cases ; on the following day, in five cases ; on the third day, in three ; the fourth, 
in one ; and on the seventh, eighth, and ninth days from admission, also in one 
case each. The general circumstances of the cases were also more favourable 



232 



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[July 



for treatment than either of the other two sets, the mean age of the patients 
being only 19.3, and the extremes 10 and 45 ; and the mean period of admission 
the sixth day of illness. The results were also more favourable both as regards 
the mortality, and the duration of the cases cured ; the deaths being only two 
males : and the period of residence in the cases which recovered, only twenty- 
six days ; deducting the three cases in which the quinine was not given till the 
seventh, eighth, and ninth days from the admission of the patients into the 
hospital, and in which the period of residence was twenty-seven, sixty-three, 
and sixty-nine days. 

"Adding these two series of cases together, and deducting those in which, 
the remedy was only given in small doses, we get a total of thirty-five cases 
treated by quinine ; of these, twenty-five were males, of whom four died ; giving 
an average mortality of 16.0 per cent. ; and ten were females, of whom one died, 
or ten per cent. ; or in the thirty-five patients of both sexes, the mortality was 
five, or 14.2 per cent. 

"The mean period of residence of the cases cured, was, in twenty males 
(excluding the one detained eighty-four days), 27.9 days; and in six females 
(excluding the three in which, the patients did not commence the remedy till 
the seventh, eighth, and ninth days from their admission into the hospital), 
25.3 days ; or. taking the two sexes together, the mean period of residence of 
the patients was 27.3 days. 

" It will thus be seen, on comparing these results as to the thirty-five cases 
treated by quinine with those obtained in the other 119 cases, that while the 
mortality in the quinine cases was considerably greater than in the others (1.6 
per cent.), the mean period of residence of the cases cured under that treatment 
was very nearly the same as in the other cases (.8 less). 

" This statement, embracing, as it does, so large a number of cases, including 
all those treated in the hospital by quinine during a period of nineteen months, 
and that, too, in the practice of different medical men, must, I think, be regarded 
as affording a fair indication of the results of the quinine treatment, and a legi- 
timate comparison with that of the other methods. There do not appear any 
circumstances which should affect disadvantageously the results in the quinine 
cases ; indeed, the general characters of the cases so treated are rather more 
favourable for treatment than those in which, the more ordinary plans were 
pursued. If. therefore, quinine really possessed the power of cutting short an 
attack of fever, without reference to its particular type or form — and such is 
distinctly the assertion of Dr. Dundas — the average duration of the cases cured 
under that treatment, and their mean mortality, should be less than those under 
the ordinary plans ; and if such does not prove to be the case, the fair inference 
is, that the remedy does not possess the asserted power. 

"It is, however, quite possible that, though the quinine treatment may fail 
to exhibit satisfactory results, when applied to all the cases which occur, taken 
indiscriminately, without reference to their peculiar character ; when applied 
to a more select set of cases, it may prove to be capable of arresting some of 
them, or, at least, of materially mitigating their severity." 

Dr. Peacock gives the details of seven cases of fever in which he made use 
of the remedy with a view of ascertaining by direct observation, how far it 
possesses the asserted power of arresting fever, or of proving, when exhibited 
in large and frequently repeated doses, a useful auxiliary to the employment 
of other means. 

"In all these cases the most marked effect produced by the large doses of 
quinine was the depression of the power and frequency of the pulse. In one 
case the beats were only 48 in the minute on the fourth day after the com- 
mencement of the remedy, and when sixteen 10-grain doses had been exhi- 
bited ; and, in this instance, the only other effect produced by the drug was 
slight frontal headache, and singing in the ears, and the patient steadily im- 
proved during its employment. In two cases the torpor and depression of 
strength increased under the use of the remedy; but, as these symptoms sub- 
sided, while it was still persevered in, it is not clear whether they should be 
ascribed to the action of the quinine or to the natural progress of the disease. 
In one case only was there more than transient headache or vertigo from the 



1856.] 



Medical Pathology and Therapeutics. 



233 



use of the remedy ; and this was also the only case in which there was very 
marked tinnitus aurium. In one case there was decided deafness, but, in this 
instance, the hearing was impaired from the time of the patient's admission. 
In one of the only two cases in which vomiting occurred, an emetic had been 
given at the commencement of the treatment. In one case the diarrhoea, pre- 
viously present, was considerably aggravated under the use of the quinine/ 7 
The' general results of the treatment may be stated as follows : — 
" I. In one of the cases of typhus, the quinine was certainly not productive 
of any benefit, and probably added to the torpor and depression of strength. 
In the other case of typhus it produced the most marked depression, and the 
patient was only saved by its discontinuance and the liberal exhibition of 
stimulants. In both cases, though the patients recovered, the disease seemed 
to follow its natural course, and to be in no degree curtailed in duration by the 
exhibition of the remedy. 

"2. In one case of typhoid, the depression of power and torpor increased 
under the use of the quinine, but the notes are too imperfect to allow me to 
speak confidently as to its effects. The patient recovered after an illness of 
average duration. 

"3. In two other cases of typhoid, the remedy appeared to exert neither bene- 
ficial nor injurious effects ; the disease followed its usual course, and the 
patients recovered. 

"4. In another case of typhoid, it certainly added to the torpor and depres- 
sion. The remedy was only exhibited in small doses, and for a short period, 
and was entirely discontinued after six dose3 had been given, in the course of 
a day and a half, and stimulants and other means were then freely had re- 
course to; the prostration and torpor, however, increased, and the patient 
died comatose. 

"5. In the fifth case of typhoid, in which the affection was combined with 
bilious complication, the quinine was decidedly beneficial, the patient steadily 
improving under its use. The attack was certainly of shorter duration and 
less severity than might have been expected from the urgency of the symptoms 
when the treatment was commenced ; but, in this case, the amendment was 
gradual, and no sudden improvement in the symptoms at any time occurred. 

" In all the cases the patients had stimulus and support as required, and other 
accessory treatment, such as astringents, aperients, and anodyne?, etc. WTiile 
also the quinine was exhibited in the various cases in different doses and at 
various intervals, the different results bore no relation to any of these circum- 
stances. 

" The facts and observations which I have now related must only be regarded 
as a contribution towards the solution of the question of the usefulness of 
large and repeated doses of quinine in the treatment of the continued fevers of 
this country. So far, however, as they go, they are opposed to the views of 
Dr. Dundas, that quinine possesses the power of cutting short the attack : on 
the other hand, they indicate that the remedy is, in some cases, beneficial ; 
but only as an auxiliary to other measures. It remains to decide, by more 
extended observations, in what forms of fever, and under what peculiar cir- 
cumstances, local and individual, the remedy may be advantageously em- 
ployed ; and whether the quinine is more useful in moderate doses at distant 
intervals, or in the large and frequently repeated doses which have been 
recommended." 

8. Bronzed Skin and Disease of the Supra-Renal Capmles. — In our last 
number (p. 489 et seq.), we noticed the connection which has recently been 
pointed out as existing between bronzed skin and disease of the supra-renal 
capsules. Mr. Jonathan Hutchinson has given [Med. Times and Gaz., March 
8, 1856), in a tabular form, the prominent characters observed in twenty-seven 
cases, and which tend very conclusively to support the opinion that the pecu- 
liar bronzing of the skin is really indicative of a fatal cachexia, and of organic 
disease of the supra-renal capsules : — 



234 



Progress 



of the Medical Sciences. 



[July 



6 


Reference. 


02 


6 

< 


Occnpation, etc. 


Previous 
health, etc. 


First symptoms. 


Degree of bronzing. 


1 


Dr. Addison's 
Work, p. 9. 


M. 


32 


Baker. 


No history given, 
excepting that the 
skin was white 
when in health. 


Troublesome cough, 
followed very short- 
ly by debility and 
bronzing of skin. 


Colour of a mulatto ; 
scrotum and penis 
darkest. (See Plate I.) 


2 


Dr. Addison's 
Work, p. 12. 


M. 


35 


Tide-waiter, mar- 
ried ; exposed 
to weather, and 
often living on 
salt provisions. 


Rheumatism eight 
years ago ; of bil- 
ious temperament 
but generally in 
good health. 


An acute illness, 
with vomiting, con- 
stipation, headache, 
and delirium ; much 
debility was left by 
this, and the bronz- 
ing of the skin soon 
followed. 


Dark olive brown ; pig- 
mentary deposits in 
lining of lips. (See 
Plate II.) 


3 


Dr. Addison's 
Work, p. 15. 


M. 


26 


Carpenter ; mar- 
ried ; intempe- 
rate. 


Very good until 3 
months before the 
change in colour 
was noticed. 


Pain in the back and 
right leg, followed 
by debility, wast- 
ing, and attacks of 
giddiness. 


Dark olive brown, — 
deepened in patches. 
(See Plate III.) 


4 


Dr. Addison's 
Work, p. 19. 


M. 


22 


Stonemason. 


No history. He 
died the day after 
admission into 
Hospital. 


Liability to pain in 
stomach, and vo- 
miting ; tic dolou- 
reux. 


Face, axillae and hands 
of a dingy bronzed 
colour. 


5 


Dr. Addison's 
Work, p. 23, 
from Doctor 
Bright' s Re- 
ports. 


F. 


Ad't 


Not stated. 


No history. 


No history. 


" Complexion very 
dark." 


6 


Dr. Addison's 
Work, p. 25. 


M. 


- 


A barrister of 
middle age. 


No history. 


No history. 


Surface generally dark 
and dingy ; face, neck 
and a rms covered with 
patches of deep chest- 
nut-brown ; — patches 
of white skin inter- 
spersed. (Plate XI.) 


7 


Dr. Addison's 
Work, p. 30. 


F. 


60 


Not stated. 


No history. The 
cancer of the S. 
R. C. was second- 
ary to cancer of 
the breast. 


Cancer of the breast. 


The colour of the skin 
of the arms, chest and 
face was of a peculiar 
light-brown, swarthy 
hue. 


S 
9 


Dr. Addison's 
Work, p. 32. 

Dr. Addison's 
Work, p. 35. 


F. 
M. 


53 
53 


A servant ; sin- 
gle* 

Sailor ; married ; 
sober. 


Always thin, but 
of good health. 

Very good ; a mus- 
cular, strong-built 
man. 


An eruption on the 
skin four months 
before, which being 
cured, stomach 
symptoms began. 

About two months 
before admission be- 
gan to lose appetite 
and feel generally 
unwell. 


Skin generally very 
dark ; axillae and 
areola of umbilicus 
remarkably dark ; — 
patches darker than 
surrounding skin. — 
(Plates IX and X.) 
The face of yellow 
bronzed tint, and grew 
darker while under 
observation. (See PI. 
VI.) 


10 


Dr. Addison's 
Work, p. 33. 


F. 


28 


Not stated. 


Died of cancer of 
uterus ; the dis- 
ease of S. R. C. 
being secondary. 


Those of cancer of 
the uterus. 


" A peculiar dingy ap- 
pearance." 



1856.] 



Medical Pathology and 



Therapeutics. 



235 



General symptoms, complica- 
tions, etc. 



Whole du- 
ration of 
disease. 



Mode 
of death. 



Autopsy. 



Eemarks. 



Excessive weakness ; some 
emaciation ; of puerile de- 
meanor ; urine healthy ; pain 
in left lumbar region ; cough ; 
sense of soreness about epi- 
gastrium. 

Pinched, anxious expression; 
tendency to vomiting ; pulse 
of usual frequency, but ex- 
tremely feeble ; liable to occa- 
sions of alarming depression; 
constipation of bowels; ten- 
derness at epigastrium ; numb- 
ness of fingers, legs, and tip of 
tongue occurred early, but 
passed off. 

Thin, pale, and very feeble ; 
liable to fainting on rising 
from bed; sickness and hic- 
cough ; pain in back ; partial 
loss of consciousness at times ; 
angular curvature of spine; 
leucoeythemia. 

Sickness, vomiting, and pain in 
stomach ; great debility, and 
some emaciation. The pros- 
tration preceding death was so 
peculiar as to suggest that 
some poison had been taken. 

Extreme debility; bilious vo- 
miting; emaciation consider- 
able ; abscess in the breast, 
and swelling of the right paro- 
tid. " There was no indication 
but to support her strength." 
—Dr. Bright. 



Emaciated, but not to an ex 
treme degree ; great anaemia 
extreme languor ; stomach ex 
ceedingly irritable, and vo 
miting urgent and distress' 
ing ; pulse of good size, but 
exquisitely soft and conipn 
ible. 

No history. The woman died of 
ulcerated cancer of the breast, 
and the diagnosis of diseased 
S. E. C. was only formed when 
in the post-mortem theatre, 
the bronzing of the skin was 
first noticed. 

Emaciated and very feel 
much irritability of stomach. 



Sensation of sickness, but no 
actual vomiting; complained 
only of weakness and loss of 
appetite ; rigors every five or 
six hours ; no pain ; pulse 80 
rather feeble ; bowels irrita 
ble. 



Until the body was in the post- 
mortem theatre, the discolora- 
tion of the skin was not no- 
ticed ; it was then remarked, 
and disease of the S. E. C. fore- 
told. No history of symptoms 
had been preserved. 



3 years. 



6 months. 



7 months. 



Several 
months. 



Not 
stated. 



1 year. 



Not 
stated. 



4 months. 



months. 



Acute pericardi- 
tis and pneumo- 
nia. 



Not stated. 



Not 
stated. 



Gradually sank 
into a torpid or 
typhoid state. 



Died from col 
lapse, without 
apparent cause 



Gradually sank ; 
before death be- 
came drowsy ; 
had pain in fore- 
head, and was 
liable to " wan- 
der" occasion 
ally. 



" The patient 
speedily sank.' 
No details given 



Not stated. 



Died " of ex 
haustion" three 
days after ad 
mission. 



He became gra 
dually weaker 
and weaker, 
and so died. 



Died of exhaust 
ion from cancer. 



S. E. C. both as hard as 
stones, as large as eggs, 
and quite destroyed. 
Evidences of recent peri- 
carditis and pneumo- 
nia ; no tubercle ; no 
other visceral disease. 
S. R. C. both contained 
compact fibrinous con- 
cretions. Inflamed gas- 
tric mucous membrane ; 
no tubercle ; no other 
visceral disease. 



S. E. C. each completely 
destroyed and converted 
into a mass of strumous 
deposit ; psoas abscess, 
and caries of lumbar 
vertebrae ; tubercle in 
lungs ; spleen rather 
large. 

3. E. C. wasted and de- 
stroyed, weighing toge- 
ther only 49 grains. No 
other important disease. 



"The only marked dis 
ease was in the S. E. C. 
both of which were en 
larged, lobulated, and 
the seat of morbid de 
posits, apparently of 
scrofulous character 
They were four times 
the natural size ; the left 
had suppurated. 
The S. E. C. both greatly 
enlarged, of irregular 
surface, and much indu 
rated ; natural structure 
lost ; microscope could 
find no nucleated cell 
no important disease of 
other organs. 
" Both S. E. C. contained 
a considerable amount 
of cancerous deposit, in 
vading their entire struc 
ture." — Dr. Lloyd. 



Cancer of the pylorus : 
left S. E. C destroyed 
by cancer. 



Tubercular deposit was 
found in one S. E. C. ; 
tubercular matter i 
also in the spleen, and 
the kidneys were dege 
nerate ; lungs not exa- 
mined ; deposit of black 
pigment in omentum 
mesentery, and cellular 
tissue of abdomen. 

The right S.E.C. healthy ; 
the vein emerging from 
the left was obstructed 
by a malignant tuber 
cle, and the organ itself 
occupied by a recent ex- 
travasation of blood, its 
structure being other 
wise healthy. 



A very well marked 
case ; no chronic dis- 
ease found at autopsy 
excepting in the S. 
E. C. 



The deposits in the S, 
E. C. resembled tu- 
bercle, but there was 
no tubercle in other 
organs. 



The blood was exam 
ined both before and 
after death, and con 
tained a large excess 
of white corpuscles 



The disease of the 
E. C. was an at: 
phy, apparently con- 
sequent on inflamma- 
tion. 

The account of this 
case was recorded by 
Dr. Bright long before 
any suspicion was en 
tertained as to the 
importance of disease 
of the S. E. C. 



In this case the vomit 
ing had been so 
urgent that the idea 
of malignant disease 
of the stomach had 
been suggested. 



In this case the extent 
of change of colour in 
skin was proportion 
ed to that of the dis 
ease of S. E. C, one 
of them being yet 
sound. 

In this case only one 
S. E. C. was disorgan 
ized, and the degree 
of bronzing appears 
to have been only 
proportionate. 



In this case the degree 
of bronzing was but 
slight, the disease af- 
fecting but one cap 
sule, and being of but 
recent occurrence. 



236 



Progress 



of the Medical Sciences. 



[July 



© 


Reference. 


ZD 


Age. 


Occupation, etc. 


Previous 
health, etc. 


First symptoms. 


Degree of bronzing. 


11 


Dr. Addison's 
Work, p. 39. 


M. 


Ad't 


Not stated. 


Died of cancer of 
lungs, etc. 


Those of cancer in 
the thorax. 


" The patient's face 
presented a dingy 
hue." Freckles about 
the face, and brown 
discoloration at root 
of nose and angles of 
mouth. 












12 


Med. Times & 
Gaz., Dec. 15, 
1S55, p. 593. 
(Dr. Burrows) 


M. 


24 


Hawker ; single. 


Had lumbar ab- 
scess in child- 
hood. 


Pain across the back, 
followed by emacia- 
tion and bronzing of 
skin. 


Of a dark copper- 
bronzed tint general- 
ly; patches of lighter 
skin on chest and bel- 
ly ; skin of penis and 
scrotum almost black. 


13 
14 


Med. Times & 
Gaz., Jan. 19, 
1856, p. 60. 
(Dr. Gull.) 

Medical Times 
and Gazette, 
Jan. 19, 1856, 
p. 62. (Mr. 
(Bakewell.) 


M. 
M. 


24 
28 


Carpenter ; tem- 
perate. 

Labourer. 


Robust. 
Not known. 


Debility ; breathless- 
ness on exertion ; 
nausea ; " bilious- 
ness." 

Not known. 


Skin generally of a 
sallow olive brown. 
The dark colour most 
marked about the 
knees ; inside of lips 
mottled with black 
pigmentary deposit. 

Skin generally of deep 
brown or bronzed ap- 
pearance, the tint be- 
ing darkest over the 
thighs. 


15 


Med. Times & 
Gaz., Feb. 20, 
p. 189. (Dr. 
Thompson ; 
Mr. Sibley.) 


M. 


20 


Baker ; sober. 


Good. 


Bronzing of the skin. 


Skin generally of a pe- 
culiar, dark, dirty- 
brown colour. 


16 


Med. Times & 
Gaz., Feb. 23, 
1856, p. 190. 
(Dr. Kowe.) 


M. 


20 


Not stated. 


Delicate. 


Delicate health, and 
bronzing of skin. 


Skin generally brown, 
with some darker 
spots. 


17 

IS 


Med. Times & 
Gaz., Mar. 8, 
1856, p. 233. 
(Dr. Farre.) 

Dr. Addison's 
Work, p. 29. 


M. 
M. 


37 
60 


A publican; in- 
temperate. 

Not stated. 


A year before had 
suffered from pain 
in the lumbar re- 
gion, which sub- 
sided under sim- 
ple measures. 
No history. 


He was admitted for 
delirium tremens. 

No details. 


Skin generally of a 
peculiar yellowish- 
brown. 

Skin generally dark 
and bronzed, with 
patches blanched and 
white. (Plate XI.) 


10 


3fed. Times & 
Gaz., p. 233. 
(Dr. Stocker.) 


M. 


56 


Physician. 


Dyspeptic, but not 
otherwise in bad 
health. 


General malaise and 
irritability of sto- 
mach ; increasing 
debility and ema- 
ciation. 


Patches of dark brown 
discoloration first ap- 
peared about the neck, 
hands, and abdomen. 
These increased, but 
the face remained, ex- 
cept some small patch- 
es, of natural colour. 


20 


Med. Times & 
Gaz., Dec. 15, 
1855, p. 594. 
(Mr. Startin.) 


M. 


12 


At school ; Irish. 


Had suffered from 
abscesses in the 
neck and slight 
cough, but was, 
on the whole, 
strong and ro- 
bust. 


Loss of flesh and gra- 
dually increasing 
languor ; fanciful 
appetite. 


Copper brown in all 
parts, the face and 
neck being tinged 
deepest. 



1856.] 



Medical Pathology and Therapeutics. 



237 



General symptoms, complica- 
tions, etc. 



Whole du- 
J ration of 
disease. 



Mode 
of death. 



Autopsy. 



Remarks 



No history preserved, the na- Not 
ture of the disease not havingi stated, 
been suspected during life. 



Irritability of stomach, with S months, 
vomiting ; pain across the 
back ; great debility ; emacia- 
tion ; partial loss of appetite;; 
urine natural. 



Nausea; vomiting; great mal- o months. 
aise and exhaustion ; emacia- 
tion ; urine healthy ; blood I 
loaded with white corpuscles. 



He was known to have been for Unknown 
some weeks in a low weak 
state ; no further history ; not 
materially emaciated. 



Became suddenly languid, then 6 weeks. 

sank into collapse, and died! 

after a three days' illness ; no 

rigors had preceded it; his 

friends had for six weeks no-i 

ticed the change in tint of the. 

skin, but there had been no 

other symptom. 
Had also disease of the knee- 8 months. 

joint ; general health rather' 

improved, until within three 

days of the fatal seizure; he 

remained muscular and fat 



Died of cancer. 



!He died after a fortnight's ill 
ness from delirium tremens. 



A.nsemia ; extreme feebleness of 
heart's action; uneasiness and 
irritability of stomach ; slight 
cedema of upper extremities 



Great debility and wasting; no 
organic disease excepting that 
of the S. R. C. being indicated. 



Some emaciation ; great and in- 
creasing debility; heavy op- 
pressed aspect ; urine healthy. 



3 weeks or 
more. 



Not 
stated. 



About 6 
months. 



9 months. 



Died from ex- 
haustion conse- 
quent on the 
action of an ape- 
rient dose. 



|Died rather sud- 
denly, from ex- 
haustion. 



Diedfromthe ex- 
haustion conse- 
quent on a short 
j ourney. 



Died in collapse. 



Diarrhoea, fol 
lowed by an 
epileptic fit ; a 
succession of 
fits, attended by 
incessant vo 
miting and oc 
casional delir 
ium ; ended in 
death on the 
fourth day. 
Sank into a ty- 
phoid state with 
low delirium 
for some days 
before death. 

Died of debility 
cancer in the 
mediastinum 
was suspected. 



No. LXIIL— July 1856. 



Sank from ex- 
haustion. 



Sank under an 
attack of diar- 
rhoea, and just 
before death 
had a succes- 
sion of convul- 
sive spasms, 
(epileptic ?) 

16 



One S. R. C. entirely dis 
organized by cancer, the 
other healthy. 



Both S. R. C. contained 
pus, and some concrete 
bodies resembling har- 
dened tubercle ; there 
was no active disease of 
the vertebrae, nor any 
important lesion of other 
viscera. 

Both S. R. C. atrophied 
and destroyed, the left 
contained cysts, the right 
some solid concretions ; 
no other organs exam 



Both S. R. C. completely 
atrophied, and contain 
ing calcareous concre 
tions ; emphysema of 
the lungs, and fatty de 
generation of the heart 

Each S. R. C. enlarged to 
the size of half a kid 
ney ; their structure was 
quite destroyed, being 
converted into a firm tu- 
bercular-like material, 
and in parts softened 
down. 

Both S. R. C. destroyed, 
and containing cheesy, 
gritty, and semi-puru- 
lent deposit ; a complete 
examination was made, 
and no other visceral 
disease of importance 
was discovered. 



In this case but one 
capsule was affected, 
and the bronzing 
was proportionately 
slight. A note as to 
the discoloration of 
skin had been taken 
during life, and with- 
out any suspicion of 
diseased S. R. C. 

In this case the chain 
of morbid phenome- 
na was very com- 
plete. 



Both S. R. C. were con- 
verted into abscesses, 
but their cortical struc- 
ture was not wholly de- 
stroyed ; circumscribed 
abscess in the liver. 

No autopsy. 



This appears to have 
been idiopathic di; 
ease of the S. R. C. 
no tubercle was found 
in other organs. 



In this, as in case 23 
a peculiarly disagree 
able odour was ob 
served to exhale from 
the patient's body for 
three or four weeks 
before death. 



No autopsy. 



No autopsy. 



In this case the sup 
purative inflamma 
tion of the S. R. C, 
had probably been 
acute and quite re- 
cent. 

This case, Dr. Addison 
states, bore the closest 
resemblance to case 
No. 6. The cachexia 
was precisely that of 
diseased capsules. — 
cancer in the medias- 
tinum was suspected 
from the oedema of 
the upper extremi- 

In this case the pre- 
sence of the bronze 
patches enabled Dr. 
Addison to predict 
the patient's speedy 
death at a period 
when there were nc 
other alarming symp- 
toms. 

For four months be- 
fore death, the boy 
had been getting gra"- 
dually weaker and 
weaker. 



238 



Progress of the Medical Sciences. 



[July 





Reference. 


X 
CO 




Occupation, etc. 


Previous 
health., etc. 


First symptoms. 


Degree of bronzing. 


21 


Med. Times & 
Gaz., Dec. 29, 

1855, p. 648. 
Ibid.,M&y2i, 

1856, p. 519. 
(Dr. Peacock) 


F 


14 


At school. 


Healthy. 


Lassitude ; muddy 
complexion, and 
slight cough. 


Of a brown muddy tint, 
deepest on face, arms, 
and shoulders. No 
mottling. 


22 
23 


Med. Times & 
Gaz., Jan. 19, 
1856, p. 61. 
(Dr. Burrows) 

Med. Times & 
Gaz., Feb. 23, 
p. 191. (Dr. 
Rowe.) 


F. 
M. 


28 
45 


Married ; tem- 
perate. 

Carter; married; 
temperate. 


Delicate. 
Robust. 


Menorrhagia and 
subsequent debility 
2 years before the 
change of colour. 

Spots of dark tints in 
various regions of 
the body. At first 
there was no illness 
or discomfort. 


A tawny or yellowish 
brown tint, most deep- 
ly marked on the face, 
arms, thighs, and legs. 
Patchy discoloration 
in parts. 

Skin generally of dusky 
brown, not unlike a 
Mulatto ; darker in 
some parts than in 
others. 


24 
25 


The Associa- 
tion Journal, 
Jan. iv, p. -±li. 
(Dr. Budd.) 

The Associa- 
tion Journal, 
Jan. 19, p. 43. 
(Dr. Budd.) 


F. 
F - 


42 
40 


Married. 
Not stated. 


Good. 
Not stated. 


A brown tinge of 
skin, followed by a 
three weeks' illness 
(typhus fever), after 
which the bronz- 
ing became more 
marked. 


Tint of skin generally 
like that of a North 
American Indian ; cer- 
tain parts darker than 
others. 

Very dark, general dis- 
coloration, large black 
patches in mouth. 


26 


Med. Times & 
Gaz., Feb. 23, 
1856, p. 189. 
(Dr. Thomp- 
son.) 


M. 


33 


Married. 


Good. 


Paroxysmal pain in 
the abdomen ; loss 
of strength ; ame- 
norrhea. 


The skin generally be- 
came suddenly of a 
peculiar dirty brown 
tinge. 


27 


3 fed. Times & 
Gaz., Dec. 22, 
1855, p. 629. 
(Dr. Eankin.) 


F. 


58 


Married. 


Formerly very 
stout and of large 
frame. 


Loss of strength and 
flesh. 


Face and hands dark 
brown ; " as brown as 
a Japanese ;" other 
parts not seen. 



9. Starch as an External Application in Cases of Smallpox and other Skin 
Diseases of an Inflammatory Nature. — Dr. Thos. W. Belcher extols {Dublin 
Hospital Gazette, April 1, 1856,) the efficiency of starch used externally, in 
skin diseases generally, and more particularly in smallpox. He relates several 
cases of smallpox in which he used the starch. This article is made thick, and 
frequently applied. The entire surface of the body was sponged with tepid 
water at least once daily, after which the mucilage of starch was immediately 
laid on. It allays the itching, and completely prevented pitting. 



SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE 

SURGERY. 

10. Amputations. — Dr. Menzies read a very interesting paper on this subject 
before the Military Medical and Surgical Society (Feb. 28, 1856). 

Although, he remarked, the works of our most distinguished civil and mili- 
tary surgeons would appear to embrace and elucidate every point of the question 
or difficulty connected with the subject, the matter he had selected for the So- 
ciety was one of interest at the present time, and, without venturing to suggest 
any novelty or theory of practice, he felt it a duty to elicit every possible in- 
formation which might hereafter tend to preserve either life or limb. Three 



1856.] 



Surgery. 



239 



General symptoms, complica- 
tions, etc. 



Countenance expressive of ex- 
treme languor ; some emacia- 
tion; great debility; liability 
to faintings, and to short 



Appetite very bad, some thirst ; 
great debility ; pains in the 
loins ; menorrhagia ; expres- 
sion languid and anxious. 



No material loss of general 
health until within a few 
weeks of death ; debility then 
supervened, and loss of appe- 
tite; great irritability of sto- 
mach ; failure of memory for 
some months ; urine normal. 

About eight months after the 
first bronzing was noticed, she 
began to lose flesh and 
strength; a harassing cough 
now occurred ; irritability of 
stomach ; extreme ansemia 
and debility. 

Anaemic, and extremely feeble ; 
sickness and vomiting. 



Previous to the change in co- 
lour of skin, she had been 
anaemic and very feeble. Co- 
incident with that change, she 
fell into a peculiar collapse, 
and continued for several days 
much prostrated. 

Sinking at pit of stomach ; nau- 
sea ; complete loss of appetite ; 
great and increasing loss of 
strength. Heart's action very 
feeble ; secretions healthy. 



Whole du- 
ration of 
disease. 



18 mont's 



7 months. 



3 years. 



16 mont's. 



Not 
stated. 



5 weeks. 



Mode 
of death. 



Died suddenly in 
an epileptic fit ; 
had been pro- 
gressively los- 
ing strength up 
to the time of 
death. 
Not known. 



He sank under 
incessant vomit- 
ing ; delirium 
preceded death. 



Gradually sank 
from exhaust- 



Gradually sank 
from exhaust- 



Recovered under 
the use of to 
nics, and the 
skin resumed 
its condition of 
simple pallor. 



Still 



lvmg. 



Autopsy. 



A chalky concretion 
found in the medulla 
oblongata ; supra-renal 
capsules were not ex- 
amined. 



No autopsy. 



At the autopsy, the chief 
condition noted was the 
presence of tubercle in 
the lungs. The S. E. C. 
were not examined. 



No autopsy. 



No autopsy. 



Recovered. 



Living at the time of Re- 
port. 



Remarks. 



A peculiar and dis- 
gusting odour was no- 
ticed to exhale from 
the body a few days 
before death. Seeca'se 
16. 

Eight months after the 
change in colour be- 
gan, the patient was 
confined of a healthy 
infant, which did 
well. 

This case is very im- 
perfectly reported, 
but is stated to have 
resembled very close- 
ly the preceding one. 

In this case the dis- 
ease of the S. R. C. 
might be conjectured 
to be merely inflam- 
matory, and, there- 
fore, susceptible of 
cure. 

In this case the symp- 
toms all combine to 
indicate the renal- 
capsular cachexia. 



questions suggested themselves : 1st. In any given case, why should we 
amputate? 2d. When should we amputate? and 3d. How, or in what manner 
should the amputation be performed? The first and second questions involved 
the nature and extent of the injury, the condition of the patient, and the cir- 
cumstances of locality, both present and eventual. They comprised what was 
called Conservative Surgery, and, if he might use the expression, the antago- 
nistic radicalism of Surgery. He would therefore ask in the first place, What 
extent of lesion of soft parts without detriment to a principal artery or fracture 
of bone can justify amputation? Most of us have seen a fatal shock to the sys- 
tem by a large shot or fragment of shell traversing the axis of a limb, or pass- 
ing through its soft parts. He remembered a soldier of the 79th Highlanders 
wounded in the trenches by a large fragment of a shell passing transversely 
through the muscles of both thighs, but without injuring the bone, which case 
terminated fatally in four hours. This case proved fatal, in consequence of not 
applying a tourniquet, as the track of the large vessels of the limb was not in- 
jured. He would, therefore, caution his younger brethren against neglecting 
so simple a precaution, as many causes may tend to produce hemorrhage during 
the transit of the patient to the hospital. In such cases he considered our duty 
was to assist nature in the subsequent extensive suppuration, for it is astonish- 
ing to what an extent injury of the soft parts may be repaired. He then men- 
tioned a case in which the arm and leg were both extensively injured : The arm 
was amputated on the field, but in the leg the foremost artery had been laid 
bare, just below Poupart's ligament; two inches of the thumb had been exposed ; 
still it gradually covered over. Everything was against this man, from the 
nature and extent of the injury, the prostration from his wounds and the ampu- 



240 



Progress of the Medical Sciences. 



[July 



tation, and the circumstances which precluded his being treated in the Crimea. 
He imagined, therefore, from this and similar cases, that in the majority of 
uncomplicated lesions of soft parts, if the system rallies from the first shock, 
the chances are in favour of recovery without amputation. He then referred to 
the valuable properties of the compound tincture of benzoin, or friar's balsam, 
in extensive lacerated wounds ; it would be of advantage more especially in a 
long passage by sea to the hospital, after an action, as had already occurred in 
the Crimea. Where sloughing had actually occurred, the application of pure 
nitric acid (but not beyond the dead surface as in hospital gangrene) speedily 
converts an offensive source of irritation and fever into an innoxious, inodorous 
healthy substance, and greatly expedites its removal. The infliction of a wound 
on the principal artery of a limb, or even one of its large branches, forms a 
most serious complication in the lesions of the soft parts received in action : 
happily it is not frequent, as arteries, from their elasticity and peculiar struc- 
ture, often escape ; still it does occur, and the question is, what influence it 
should have on our practice. A man of the 93d Highlanders was wounded by 
a ball in the popliteal space, and the artery opened. The vessel was skilfully 
tied by Dr. Logan, above and below. Mortification ensued, and amputation 
was performed as a dernier i^essort, and the man died. Now, although there 
can be little doubt that, had amputation been performed in the first instance, 
this man's life would have been saved, it does not follow that this would have 
been the correct practice. He trusted that we might hear some results of the 
experience of Alma, Balaklava, and Inkerman on this point. His own opinion 
was, that, unless under very peculiar circumstances, the primary consideration 
should be the immediate security of the patient's life by deligation of the artery, 
leaving amputation to follow as a possible but not probable consequence. Our 
next consideration was regarding fractures of bone received in battle as con- 
nected with amputation. The solution of continuity will of course depend 
much on the missile, etc. Limbs have not much chance in the track of a round 
shot or shell, and leave us little choice of action. He believed that as regarded 
the upper extremity and below the knee an ordinary bullet will waver, and a 
Minie seldom causes such extensive comminution as to justify amputation. The 
old bullet was easily turned in its course, but the Minie produced longitudinal 
fracture and sometimes comminuted it in an extraordinary manner ; still the 
reparative process of fracture was often equally extraordinary. He then men- 
tioned a case in point. The success that had attended the operation of resection 
of joints proved that it was not absolutely necessary to amputate because a ball 
had not penetrated any articulation of the upper extremity, or a fracture ex- 
tended into it. Wounds of the carpus and tarsus were also amenable to the 
principles of conservative surgery, of which he had seen several admirable re- 
sults. He would now refer to compound fractures of the thigh — though last, 
the most important, and embracing the first question, Why should we ampu- 
tate? It was a most serious and sacred duty of the surgeon to weigh well this 
question. All personal feelings of eclat or vanity must be spurned. At the 
cavalry charge of Balaklava General Canrobert exclaimed, "Mais ce n'est pas 
la guerre;" and although it may be equally magnificent to a professional eye 
to see Weiss's bright steel flashing through wounded limbs in graceful curves, 
it was not always surgery. There was no operation that he would not have an 
honest pride in performing ; but he maintained that it was not always necesary 
to amputate in compound fracture of the femur. Can life be-insured when am- 
putation of the thigh was performed ? certainly not. Must it be sacrificed with- 
out a hope of saving the limb ? certainly not. There is a living proof to the con- 
trary this moment in the camp. Under what more unfavourable circumstances 
could the wounded have been placed than after Alma, Balaklava, and Inker- 
man ? Still the cases proved remarkably successful. He then referred to the 
modes of protecting the limbs from motion during very rough transit, to which 
military men, under such circumstances, were subject, and recommended the 
gutta percha splint, and also observed on the best mode of applying it. The 
French surgeons said they now never attempted to save a compound fracture 
of the femur; no doubt many English surgeons held the same opinion. He was 
aware that those cases required extreme vigilance ; but what had happened 



1856.] 



Surgery. 



241 



might happen again, and he trusted that attempts would be made to preserve 
the limb in such cases, should we have another campaign. The rifie bullet 
generally split the femur in the direction of its fibres. His experience of 
wounds of large joints led him to the conviction that either amputation or re- 
section must be performed to give the patient a chance of his life. He was in 
favor of the resection of joints. The next question was, When is it to be per- 
formed? Is it to be primary or secondary ? Primary operations he considered to 
be \vithin thirty-six hours, or before adhesive inflammation had fairly set in. 
The consequences of secondary operations during that period were very fatal 
when the operations were delayed to the true secondary period. "When the 
constitution had become in some degree accustomed to the drain on the sys- 
tem, the results became very favourable. He then gave some tables of the re- 
results of secondary operations at Scutari, but the returns were not very com- 
plete ; however, the conclusion naturally was, that if amputation were to be 
performed, the sooner it was done the better after the receipt of the injury ; 
and if delayed, no operation should be performed until local and constitutional 
circumstances were favourable. He would continue the subject on another day. 

Dr. Williams said that as the practice of some was very different from 
what had been so ably stated by Dr. Menzies, he hoped that those who were 
there from the commencement of the war would give their experience. With 
reference to the tincture of benzoin for wounds, he had not used it himself, but 
had found copaiba of the greatest use in lacerated wounds. 

Mr. Blenkins felt sure the author must have had considerable experience in 
gunshot wounds. He could bear his testimony to the admirable effects of the 
tincture of benzoin. He thought it a valuable remedy, and had used it in cases 
of hemorrhage from the surface of scorbutic sores with the greatest benefit. 

Dr. Crawford differed somewhat from Dr. Menzies, but agreed with him in 
cases of wounds of the humerus. He considered wounds of the large joints as 
cases for resection ; however, they were not always hopeless cases, and he 
mentioned the case of an officer of the 18th Regiment who was wounded in the 
knee-joint, treated by Dr. Ryan, 18th Regiment, by rest, and whose limb was 
saved without an operation. Compound fractures of the femur were also not 
without such success as to leave hope of saving the limb. He also mentioned 
some cases of compound fracture of the tibia that afterwards required opera- 
tions ; still he in general agreed with Dr. Menzies, that many cases would still 
require operations. 

Dr. Trotten mentioned a case at Scutari of a wound of the knee-joint, where 
an attempt was made to save the limb, but amputation was subsequently re- 
quired. 

Dr. Crawford, in reply to Mr. Blenkins, said the synovia escaped from the 
wound of the knee-joint. 

Dr. Robinson could not corroborate Dr. Menzies' statement of the advisability 
of preserving the limb, where the injury was below the knee ; the amount of 
injury almost always required amputation, and if not done primarily, would 
require to be subsequently performed with more risk to the patient. 

Dr. Gordon, after a long experience here and elsewhere, never had reason to 
regret not having saved the limb when the joint had been injured; he had 
never seen a case in which the head of the tibia was injured that had recovered 
without an operation. 

Dr. O'Leary read his successful case of excision of the head of the femur. 

Dr. Shelton mentioned a case of compound fracture of the middle of the 
humerus which recovered without operation ; he was an advocate for conserva- 
tive surgery. 

Mr. Blenkins thought that Dr. O'Leary's case was a favourable one for exci- 
sion, and he had an opportunity of seeing the man while under treatment in 
the 68th Regiment Hospital, and was struck with the simplicity of the appara- 
tus employed. 

Dr. O'Leary said, that as allusion had been made to the resection of the hip- 
joint, he had read the case that had proved so eminently successful. 

Dr. Robinson had a case of gunshot wound of the knee-joint; there was no 



242 



Progress of the Medical Sciences. 



[July 



splintering of the bone, and it was considered an apt case for an attempt at 
conservative surgery. The patient, however, subsequently died. 

Dr. Gibant had seen two excisions of the elbow and two of the knee both suc- 
cessful. 

Dr. Burke said his experience during the Sutlej campaign was in favour of 
primary amputations. 

Mr. Ilodgers mentioned a case of wound of the knee-joint that proved fatal. 

Dr. Williams considered the same amount of mortality would not have 
occurred had the case happened under different circumstances. In hot climates 
he considered that primary amputations should generally be preferred. 

Dr. Gordon corroborated Dr. Burke, and said that he, out of twenty-two ope- 
rations on the upper extremity, had only lost one. 

Mr. Thornton was greatly in favour of early operations after injuries, and 
mentioned a case of a soldier whose arm he had amputated at the neck of the 
humerus, who was walking about the fifth day. 

Dr. Burke in reply to Dr. Williams said, with reference to the heat of climate, 
it was in the northwest provinces of India, where the climate is occasionally 
colder than it is here. The heat of India had nothing to do with the fatal re- 
sults in the cases he had mentioned. 

Dr. Crawford thought, as far as he could gather the opinion of the members, 
that amputation was considered necessary in cases of perforating wounds of 
the knee-joint. Inflammation of the synovial membrane appeared to have been 
the cause of dread ; but he hoped that he might live to see the day when ampu- 
tation would not be considered altogether necessary in those cases. 

Dr. O'Leary mentioned a case of wound of the knee joint in which he could 
introduce his little finger ; there could be no mistake that the joint was injured, 
as the synovia was escaping from the wound. He was going to amputate, but 
was ordered not by the principal medical officer; the man died in a few days 
of pytemia. In another case the knee was wounded by a piece of glass, the 
synovia escaped from the wound ; ice was constantly applied, and tartar emetic 
administered ; on the seventh day inflammation set in and mercury was given ; 
the joint gradually improved, the wound became chronic, and is now progress- 
ing favourably. He was of opinion that synovia may come out of a wound and 
yet the limb may be saved. This was not a clean wound. 

Mr. Wyatt considered that we should not trust too much to the absence of 
any sanguineous effusion immediately after an accident. He had no experience 
of the tincture of benzoin, but he did not approve of the tincture of matico. He 
imagined that neither of them could be applied except in cases where hemor- 
rhage occurred only from the surface of sores and wounds. The author of the 
paper, in speaking of the French practice here, in reference to the wounds of 
the middle and upper thirds of the thigh, had been somewhat in error, the fact 
being that they scarcely ever operate in such cases, but leave the patient to na- 
ture ; and they find it as successful as in cases where for similar injuries they 
had previously operated. He could bear testimony to the extraordinary course 
a Minie ball would sometimes take, and mentioned a case that occurred at 
Inkerman. 

Mr. Bowen thought the question raised respecting the employment of primary 
or secondary amputations a most important one. He could speak most favour- 
ably of the employment of aconite as an antiphlogistic remedy instead of tartar 
emetic. He did not approve of the gutta percha splints recommended by Dr. 
Menzies, but preferred those made of thin wire, which are light and cleanly. 

Mr. Wyatt had seen the splints mentioned by Mr. Bowen ; they were con- 
stantly employed in the French ambulances, and were found very useful. 

Dr. Sclaveroni said the wire splints had been used in the Sardinian army in 
a few instances, and were highly approved of. 

Mr. Blenkins had been edified by the discussion, and he proposed a vote of 
thanks to Dr. Menzies. 

11. Analysis of Cases of Amputation of the Limbs in the Radcliffe Infrmary, 
Oxford. — Edward L. Hussey, Esq. communicated to the Royal Medical and 
Chirurgical Society (April 8, 1856) the following statement: — 



1856.] 



Surgery. 



243 



"The capital operations in the Radcliffe Infirmary are recorded in a register 
kept for the purpose, the entries being made from notes taken at the time of 
the operation. In this register and in the admission-books are noted 164 cases 
of amputation from all causes, which are arranged in the paper in separate 
tables. Among the cases of disease, 91 were for diseases of joints ; 55 of these 
were in the thigh, of which 10 were fatal ; 6 died from the immediate effects 
of the operation, and 4 did not recover sufficiently to be sent home. The mor- 
tality varied in the practice of the different surgeons. Of 20 cases in the leg, 
only 1 died ; of 6 cases in the upper arm, and 10 in the forearm, all recovered. 
Among those who recovered from the operation, 17 never permanently regained 
their former health ; 3 died from accidental illness ; in 1 the cause of death was 
not ascertained ; 16 others died with phthisis, at various periods after the opera- 
tion ; the subsequent history of 5 was not known ; the rest are all now in good 
health. The mortality was not affected by the duration of the disease, or the 
extent of disorganization of the joint. The proportion of men who undergo 
amputation in early stages of disease is greater than that of women ; in later 
stages the proportion of women is greatest. The operations for diseased joints 
in boys and girls under puberty are not successful ; a larger proportion than 
in adults die from the effects of the operation, or do not recover their health 
after amputation. In 5 cases of malignant diseases, 2 died after operation ; in 
1 the disease returned within a year; the other 2 are living. In other diseases, 
necrosis, caries, gangrene, elephantiasis, old ulcerations, and inconvenient 
limbs, all the patients recovered. Of 6 cases of primary amputation of the 
thigh, only 1 recovered, and in that case the injuries were confined to the leg, 
below the knee. In all the fatal cases, the operation was performed after very 
severe injury. All the operations on the leg (12 in number) succeeded. Of 15 
on the upper arm, 3 died; and of 14 on the forearm, 1 died. Among the 
secondary operations, only 1 died, after amputation at the shoulder-joint for a 
burn. The operations were mostly done by circular incision. The chief veins 
of the limb were tied whenever they bled, without any bad consequences. The 
stumps were generally tied at the time of the operation. In several cases, 
where the stump was left open after the operation, there was secondary hemor- 
rhage, and in all of them union was very slow. The healing of the wound, or 
the discharge of the patient, was retarded by so many accidental causes, that 
it was not easy to make a fair estimate of the time occupied in the recovery. 
The forearm generally healed rather sooner than the upper arm, and the upper 
arm rather sooner than the leg, the thigh being much the latest. After ampu- 
tation for diseased joints, the stumps healed sooner than in other diseases. The 
greatest delay was after primary operations for accidents. 

"Mr. Erichsen asked how it was that the rate of mortality varied so greatly 
in the practice of different surgeons in the Radcliffe Infirmary ; whether the 
variation was accidental, or due to the adoption of different methods of treat- 
ment. The paper appeared to indicate that (as, indeed, might be expected) 
amputations and excisions for disease were on the whole more successful in the 
country than in London. Skill, he believed, had little to do with success in 
such cases. In the country the surgeon had not to deal with persons who were 
broken down by debility as in London, and he could place his patients in far 
better hygienic circumstances. The mortality at the Radcliffe Hospital did not 
appear to arise from pyaemia, secondary abscesses, and the like, which so fre- 
quently occasioned death in London. The mortality, however, in cases of 
primary amputation of the thigh, appeared to be as great there as elsewhere. 
This was, perhaps, the most fatal operation in surgery. In many institutions 
not one patient in ten had recovered. Such a result would almost lead one to 
adopt the plan of the French surgeons, who had given up the operation entirely. 
He believed that not a single case had proved successful either in the French or 
British camp. 

" Mr. Hussey said, the six deaths after amputation of the thigh resulted from 
pyaemia. He had no doubt that operations were more successful in the country 
than in London, the constitutions of the patients being better. In London he 
never saw a wound after amputation heal by the first intention. In the case 
of recovery after primary amputation of the thigh, the thigh-bone was not in- 



244 



Progress of the Medical Sciences. 



[July 



jured. When the bone was injured he had never "known a patient to recover. 
He should be glad to know the result in London of operations for diseased 
joints in children. His own impression was, that amputation for diseased 
joints was never required before puberty. Such cases, he found, recovered 
in the country ; and if they did not, amputation, he believed, would be of no 
service. 

" Dr. Barker said, he knew two officers who had recovered after primary 
amputation of the thigh ; and, he believed, without a bad symptom. 

" Mr. Paget mentioned two recent successful operations for gunshot wounds ; 
one by Mr. Hewett, at St. George's Hospital, where there was an extensive 
fracture of the lower part of the femur ; and the other by himself, at St. Bar- 
tholomew's, where the gunshot went through the condyles of the femur. In 
both cases, he said, recovery was perfect. 

" Mr. Curling thought Mr. Erichsen had taken a more gloomy view of the 
operation than facts warranted. He had seen many cases recover. 

" Mr. Erichsen said, he had in view 12 cases at Edinburgh, all of which 
died ; 10 in the Royal Infirmary, Glasgow, and the same number in St. Thomas's 
Hospital, not one of which recovered. In the hospital with which he was con- 
nected, nearly half the cases had been saved ; so that as to personal experience 
he did not take so gloomy a view as was supposed ; he simply referred to the 
statistics which had been published. 

" Mr. Arnott said, that in regard to the operation in question, the experience 
of the Peninsula was similar to that of the Crimean campaign — that it should 
not be attempted except in cases of absolute necessity." — Med. Times and Gaz., 
April 26, 1856. 

12. Excision of Elbow-joint. — Mr. Syme states {Lancet, April 19th, 1856), that 
he has recently adopted the following method of excising the elbow-joint, and 
found it to wonderfully facilitate the process. 

Having made the ordinary incisions he exposed the convex osseous surface, 
held the ulnar nerve to the side by a hook, and sawed through the bones about 
the middle of the olecranon. Nothing, he says, could be easier after this, than 
insulating first one and then the other extremity, and sawing them off to the 
requisite extent. 

13. Excision of the Knee-Joint. — By Peter Brotherston, Esq. In 1854, when 
visiting Edinburgh, I had frequent opportunities of seeing two cases, in which 
the operation of excision of the knee-joint had been successfully performed by 
my friend, the late Dr. Richard Mackenzie, of Edinburgh, in the Royal Infirm- 
ary ; and, being struck by the appearance, strength, and usefulness of the 
limbs operated upon, I determined, whenever a suitable case presented itself, 
to give the operation a trial. 

Robert Strang, v&t. 10, son of a collier residing in Clackmannan, has had 
strumous disease of the left knee-joint for two years. The leg is slightly flexed, 
the joint very much enlarged, and an ulcerated opening, about half an inch in 
diameter, over the inside of the joint. A probe, introduced into this opening, 
and pushed backwards, enters the joint. He has continual pain, aggravated 
on motion, and the discharge is very considerable. The boy is pale and ema- 
ciated, and has a quick pulse, of about 120. Having stated to the parents that 
an effort should be made to save the leg, and explaining to them the nature of 
the operation for excision of the knee-joint, they at once consented to have the 
operation performed without delay. I wrote to my friend, Dr. James Gillespie, 
of Edinburgh, requesting his assistance in this case, he having assisted the 
late Dr. Richard Mackenzie in his previous cases at the Royal Infirmary; and, 
accordingly, on the 19th May, 1854, I performed the operation as follows: The 
boy being put under the influence of chloroform, I made a free incision across 
the front of the knee-joint, below the patella, from a little above the posterior 
edge of the inner tuberosity of the tibia, across to the posterior edge of the 
outer tuberosity ; and having divided the lateral and crucial ligaments, I pro- 
ceeded to separate the connection round the condyles of the femur, which being 
done, about three quarters of an inch of the condyles were sawn off. A slice 



1856.] 



Surgery. 



245 



of about one-third of an inch in thickness was then taken from the head of the 
tibia, and the cartilage was removed from the inner surface of the patella by 
means of a gouge. Four arteries required ligature. The ends of the bones 
were then placed in accurate apposition, and the wound was closed with seven 
sutures. A splint, covered with lint, was applied to the ham, and the whole 
secured with a bandage. 

It is needless to give a detailed account of this case ; but I may remark, that 
in seven months, complete anchylosis of the bones had taken place, and the 
boy could walk with freedom. There were two or three sores in the neighbour- 
hood of the incision; but they were superficial and unconnected with the bone. 

Second Case. — The progress and cure of the case just related was anxiously 
watched by a gentleman in Alloa, whose son, eleven years of age, was labouring 
under acute synovitis and ulceration of the cartilages of the right knee. From 
seeing the case of the boy Strang progress so favourably, he asked me if a 
similar operation might not save his son's limb ; and on being told that the 
case was a remarkably favourable one for the operation, he at once consented 
to have it done. I may state there was urgent necessity for this operation, or 
amputation being immediately performed. The extreme paroxysms of pain 
which came on whenever the boy attempted to sleep, caused by the ulceration 
of the cartilage being brought in contact with the opposing bone during 
sleep, when the natural control of the limb was lost, and his state of nervous 
debility, showed that he could not have borne up longer under the source of 
irritation. There was no other external ulceration, except a sinous opening in 
the ham, which discharged a quantity of matter. I was assisted again by my 
friend, Dr. James Gillespie, and the operation was performed on the 12th Jan- 
uary, 1855, in every way similar to the former case. 

There was a considerable quantity of pus in the joint, and distinct ulcera- 
tion of the cartilage on the condyles of the femur and head of the tibia. The 
incision nearly all healed by the first intention, and everything went on 
favourably till about the beginning of March, when an abscess began to form 
on the outside of the thigh, a little above the seat of the operation. This I 
opened on the 28th of March, and shortly afterwards the abscess gradually 
closed, and finally healed altogether. It is now eleven months since the opera- 
tion was performed, and the limb is fairly anchylosed. «A11 swelling has dis- 
appeared, and the limb is as straight as its fellow, and only an inch shorter. 
The patella is found slightly movable, a little above its former seat, and he can 
walk with a firm decided step, without a crutch, although he uses one at pre- 
sent, by my orders, to save the limb. 

I may mention here the great benefit I found from the use of sand bags, re- 
commended me by Dr. Richard Mackenzie, laid on each side of the leg, along 
the sides of the joint, and fastened with two bits of tape, one above and another 
below the knee. They served admirably to keep the bones in accurate appo- 
sition, and from their weight, kept the leg in situ, especially preventing its 
movement during sleep. — Edinburgh Med. Journ., April, 1856. 

14. Tic Douloureux cured by Excision of a Mass of Phosphate of Lime, adhering 
to the Supra-orbital Nerve. — By Hugh Sharp, Esq. On the 17th of December, 
1855, a man, G. F., get. about 50 years, residing in Cullen, had a very severe 
attack of tic-douloureux in his left brow, which continued, without intermission, 
for several hours ; it again returned on the 18th, at the same hour as on 17th, 
but with greater violence, when I was called on for advice, etc. Seeing at once 
the nature of the case, and without examining minutely the seat of the severe 
pain, I prescribed for him some croton oil and calomel pills, to be taken at pro- 
per intervals. This had the desired effect, until the 20th, when the pain re- 
turned with the same violence as formerly, when I was again called in, when, 
on pointing out to the man the course of the supra-orbital nerve, which would 
have to be divided, or rather a small part of it removed altogether, in order to 
give relief, even for a limited time, I detected a small hard tumour, about the 
bulk of a pea, somewhat flattened, firmly adhering to, and immediately over, 
the supra-orbital nerve, as it emerged from the notch, and concealed by the 
eyebrow. I inquired if he knew how long the small tumour had been there, 



246 



Progress of the Medical Sciences. 



when he stated that it had been there about thirty years, but had never felt any 
pain in it, or near it, and did not think it had any connection whatever with 
the pain ; but on my stating my firm belief that the small tumour was the sole 
cause of the acute suffering, he agreed to my proposal of removing it imme- 
diately, which I proceeded to do. I thought the small tumour was a firm en- 
cysted one, but soon found out my mistake, for, on attempting to transfix it, 
my small bistoury was stopped. I then laid open the skin over the tumour, 
and grasped it firmly in a common dressing forceps, but found I could not dis- 
lodge it from its adhesions without the aid of a small scoop. This small tumour 
was in reality a small piece of phosphate of lime, which I transmitted to Pro- 
fessor Syme, along with the details of the case. 

I have further to add that the Tic was completely cured by the removal of 
the tumour, and has not again returned, even in the most modified degree, to 
the very great satisfaction of the patient. In many cases, I am of opinion that 
tic is produced by the presence of a tumour, of one kind or other, on the nerve, 
though situated so deep as to elude detection. I may here add, that the patient 
has suffered, every week almost during the past thirty years, from severe head- 
aches, but since the removal of the little tumour he has had no return of head- 
ache whatever. — Edinburgh Med. Journ., April, 1856. 

15. Gunshot Wounds. — Dr. G. H. B. Macleod, in some " Notes on the Sur- 
gery of the War" [Edinburgh Medical Journal, May, 1856), makes the follow- 
ing interesting remarks on gunshot wounds : — 

" Of the ' peculiarities' of gunshot wounds, none strikes one earlier than the 
results which flow from the fact, that their being essentially of a contused cha- 
racter, their tract must suppurate before it closes. Superficial wounds through 
muscles, sometimes, though rarely, form exceptions, as they have been seen to 
adhere by the first intention. Thus I have seen one case, in which a superfi- 
cial wound of the belly of the gastrocnemius by a ball, was said to have healed 
by the fifth day. The separation of the sloughs from the tract of a ball have, 
in the case I have had under my charge, taken place at different periods between 
the sixth and twenty-seventh days, according to the depths of the parts tra- 
versed. This separation gives rise to another feature in these wounds, the 
occurrence of secondary hemorrhage, as well as the fact, that if the orifices of 
the tract become clean and adhere while suppuration is going on within, most 
troublesome accumulations of pus and burrowing abscesses will result. The 
greater contusion at the orifice of entrance causes it, in general, though by no 
means universally, to be longer of taking on the adhesive process than the ori- 
fice of exit. 

"The eccentric course often pursued by balls, has frequently been remarked 
upon in former wars, and though we have had many most striking instances of 
this peculiarity, still I suspect we have had less of it than occurred in the ex- 
perience of former campaigns. The Minie ball is seldom content to dally with 
a limb, or run round a cavity. Its force, on the contrary, suffices not only to 
carry it through any of the great cavities, but has been seen to lodge in the 
bod}'' of a third man, after perforating that of his two front rank comrades. 
The old ball is still sometimes used, and most curious is its occasional wandering. 
Thus I have known it enter above the elbow, and be cut out from the posterior 
wall of the axilla of the opposite side, while in another instance it entered the 
right hip, and was found embedded in the left popliteal space. This circum- 
stance often makes the search for balls exceedingly difficult, more particularly 
as the feelings of the patient frequently give one but little assistance. That 
such a search should be instituted at the very earliest possible moment before 
inflammation and swelling have come on, is a most imperative maxim ; and 
unless greater injury be inflicted by its removal than is likely to follow its re- 
tention, the necessity of extracting the ball and all foreign matters it may have 
introduced along with it, is of the utmost importance, both immediately and 
remotely. Two instances may be mentioned as illustrating the necessity for 
an early and careful search — though such an obvious point hardly requires 
elucidation. One case occurred to myself. A soldier, wounded on the 18th of 
June, was brought under my care in the General Hospital in camp. He had 



1856.] 



Surgery. 



247 



sustained a compound fracture of the right arm, which was much swollen on 
admission. I was told, and accepted the story, that the accident had been 
caused by a piece of shell, to which species of injury the wound bore every re- 
semblance, and that a surgeon who had seen him in one of the trenches, had 
removed it. At the earnest solicitation of the patient, I contented myself with 
applying the necessary apparatus to try and save the limb, without minutely 
examining the wound. The injury turned out to be much masked and to be 
more severe than was at first supposed — the shaft of the humerus having been 
split into the capsule — and when removing the limb at the shoulder, some days 
after, a large grape-shot dropped out from among the muscles. I once saw a 
piece of shell weighing nearly three pounds, extracted from the hip of a man at 
Scutari, after the battle of the Alma, which had been overlooked for a couple 
of months, and to which a very small sinus alone led. This latter case, too, 
illustrates another curious circumstance in gunshot wounds, viz., the way in 
which the elasticity of the soft parts often permits bodies to pass in behind, 
which they close, so as to make it a matter of wonder how such masses could 
have got admission. 

"The sensation caused by a ball striking a limb appears to be of the most 
trivial and transient nature, and is commonly likened to a smart blow from a 
cane. If a cavity be entered, the collapse and mental trepidation are often, 
however, very appalling. 

" Shell wounds are more destructive to the soft textures than those caused by 
rifle balls, being frequently followed by wide-spread sloughing; but the hard 
parts often suffer less. The bone may be fractured, but it is frequently not 
much comminuted. The shell falling vertically, gives rise sometimes to most 
wonderful escapes. 

" The constitutional fever which follows gunshot wounds is, in general, pro- 
portioned to the importance of the part implicated, though most curious excep- 
tions to this not unfrequently arise. That old soldiers, if sober, are much less 
affected by this constitutional disturbance than others, is, I think, very ob- 
servable. The mitigation of this, and of the local inflammation, the prevention 
of all accumulations of matter, by the making of judicious dependent open- 
ings, the relaxation of several muscular fibres, the application of light unirri- 
tating dressings, rest, and attention to the general principles of surgery, com- 
prise all the treatment which gunshot wounds usually demand. In the profuse 
suppurations which so often follow these injuries, the use of cod-liver oil has 
been markedly advantageous. The extreme simplicity of the appliances and 
dressing employed during this war, and the nearly total absence of poultices 
and such like ' cover-sluts/ would, I think, merit the approbation of even Mr. 
Guthrie. The era when the 1 Oleum catellorum' and the tenting of wounds 
was in vogue, has entirely passed away forever ; and, though wondrous vir- 
tues are ascribed to water, it is not on account of any ' magical or unchristian' 
power which it is supposed to possess. Water dressing and the lightest possi- 
ble bandaging is in universal repute in this army, though not seemingly so 
popular with our allies the French, with whom grease, divers coloured washes, 
heavy pledgets of charpie and much cloth, still hold their place. There is, how- 
ever, one application to profusely suppurating wounds, which I have seen the 
French employ with more manifest advantage than many of the astringents we 
use, viz., a solution composed of the perchloride of iron in the proportion of one 
to three of water. 

"Splints, too, of the simplest pattern are now employed, and the straight 
position universally preferred in the treatment of fractures. Bandaging is re- 
duced to the fulfilment of the most necessary essentials, and all complications 
studiously avoided. Endless rollers, multiplied splints, and various contrivan- 
ces are still too often seen in the French ambulances. Stiff bandages have been 
but little used by us, though one felt much tempted to apply them after their 
recorded success in the Schleswic-Holstein war. The ' appareil amovo-inamo- 
vible' is said to be popular with our enemies, and an illustrated book on its em- 
ployment, published in 1851, for the use of the army, was found by a friend 
who was with me in the hospital library of Fort Kinburn. 

"The long believed and much feared effects of the wind of balls, has so com- 



248 



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[July 



pletely passed away into the mythology of surgery, that if it were not that one 
of my own wards, at this moment, contains two most excellent instances prov- 
ing fts utter nonsense, I would not at all refer to it. The haversack of one 
man was struck by a round shot on the 8th September, and though his back 
was slightly discolored, he was not knocked down; and the other suffered a 
trivial abrasion of the thigh by a like cause. I had lately two under my notice — 
a sergeant who was struck on the chin by a 9 lb. ball, and though it fractured 
his jaw severely, in no way affected his brain ; and another soldier had a piece 
of flesh, about the size of the fist, cleanly nipped out of his hip in the same 
way." 

16. Hemorrhage following Gunshot Wounds. By G. H. B. Macleod. — Hemor- 
rhage following gunshot wounds is not now so dreaded as it used to be, because 
it is known to be by no means so frequent in occurrence as it was formerly be- 
lieved to be. I have heard surgeons declare that tourniquets might have been 
left at home, so far as any use they were of at the battles of the .Alma and 
Inkerman, but I suspect, though cases did not often require them when seen 
by the medical man, that hemorrhage is in reality the chief immediate cause 
of death in the case of the majority of men killed in the field. It would be a 
dangerous experiment to make, but withal a very interesting one, to go over a 
field of battle immediately after a fight, and record the apparent causes of death 
in each case. 

The returns fail to inform us of the numbers of cases in which secondary 
hemorrhage succeeded gunshot wounds in the course of this war, and though I 
have no figures to which I might refer in corroboration of the statement, I am 
inclined to think that the proportion is higher than that set down by Mr. 
Guthrie. The period of its occurrence has appeared to range, on an average, 
between the fifth and the twenty-fifth day, without drawing any minute dis- 
tinction, as is done by Dr. John Thomson, between hemorrhage due to slough- 
ing, ulceration, or simply excited arterial action at different stages of the pro- 
cess of cure. The fifteenth day has, curiously enough, been that on which it 
has taken place in the vast majority of the cases of which I have retained notes. 
One instance, the particulars of which I failed to learn, was said to have oc- 
curred as late as the seventh week, when the wound — a gunshot wound of the 
thigh — was nearly cicatrized. Hemorrhage occurring early has been almost 
universally treated on the principle laid down by Bell, and so well supported and 
elucidated by Guthrie, of tying both ends of the wounded vessel ; but when the 
limb is much swollen, the parts infiltrated matted together and disorganized, it 
is all very well to say the same principles must be carried out notwithstanding 
the additional risk that the coats of the vessel may be diseased, but any one 
who has tried it a few times will know that to do so is no easy task. With a 
vessel like the posterior tibial, which has repeatedly bled and infiltrated the 
tissues of a large muscular calf, changing their appearance and matting them 
together, and with a large irregular wound, into which the blood from the ves- 
sel does not seem to be poured in a collected form, but to well out from a large 
sloughing surface, so as to afford no guide to its exact position, the undertaking 
is one of the most difficult that can be imagined. The rules and precepts laid 
down in books about passing probes from the surface towards the seat of the 
bleeding, the appearance assumed by the vessel, and the dissecting-room di- 
rections to find it, are all utterly useless in actual practice ; and the knowledge 
of them is often more a hindrance than an assistance. Watchful eyes and 
careful cutting, are the only reliable guides. 

I believe that pressure so carefully applied over a long tract of the main ves- 
sel above, as will diminish, without arresting, the stream passing through it, 
will, in many cases, be sufficient to allow such coagulation to take place in the 
open mouths of the vessels as will prevent any future annoyance — that is always 
supposing a very large extent of an artery be not ripped open, as it were, and 
as I have seen it, by a rifle ball. The French do not, seemingly, act so unre- 
servedly on the principle of putting a ligature on both ends of a bleeding ves- 
sel, as we do. They perform Anel's operation in not a few cases. The inter- 
esting and instructive nature of the following case is evident: A Russian boy, 



1856.] 



Surgery. 



249 



wounded at Inkerman, was received into the French hospital at Pera. He had 
sustained a compound fracture of the leg from gunshot. On the fifteenth day 
after injury, profuse hemorrhage took place from both openings. Pressure 
failed to arrest it. The popliteal was tied the same day according to the 
method of deligation recommended by M. Jobert, viz., on the inner side of the 
limb, between the vastus and hamstring muscles. The foot remained very cold 
for four days, and then violent reaction set in, and on the eighth day from the 
ligature of the main vessel hemorrhage recurred both from the original wound 
and the incision of ligature. Pressure was tried in vain. The superficial 
femoral was then ligatured on the tenth day from the deligation of the pop- 
liteal. Four days afterwards the bleeding returned from the wound, and 
pressure then seemed to check it. The ligature separated from the femoral on 
the twelfth day after its being tied, and the third day after, i. e , the twenty- 
fifth day from the first occurrence of hemorrhage bleeding again set in from 
the wound, the limb was amputated in the thigh, and the unfortunate patient 
ultimately recovered. Would Mr. Guthrie not have saved this man's limb and 
the surgeons much trouble ? It was a matter of common conversation in the 
hospitals at Constantinople, that when the weather was close and sultry, with 
little wind, there was certain to be a large number of cases of secondary 
hemorrhage. 

A soldier, resting his right hand on his musket, was struck by a ball on the 
web between the thumb and forefinger. The wound seemed trivial, but the 
whole hand swelled exceedingly. On the fourteenth day arterial hemorrhage 
occurred, and pressure was applied. The bleeding repeatedly recurred, and 
still pressure was persevered in. Finally the radial, and then the ulnar, was 
ligatured before the hemorrhage was commanded. An early search in the 
wound, and a thread appled to the orifices of the vessel, would have saved 
much annoyance and risk. The following occurred under my own notice: — 

M'Garthland, a soldier of the 38th regiment, an unhealthy man, who still 
suffered from the effects of scurvy, which had been followed by fever, was shot 
through the left leg from behind, and externally forwards and inwards, on the 
18th of June. The fibula was broken, and the edge of the tibia was injured. 
He walked to the rear without assistance. On admission the limb was greatly 
swollen. This swelling very much diminished in a few days. On the fifth 
day. arterial bleeding, to a limited extent, took place from both openings. Re- 
calling a case put on record by Mr. Butcher, of Dublin, the wound of the post- 
tibial, I determined on trying the effects of well-applied pressure along the 
course of the popliteal and in the wound, and employed cold, while the limb 
was raised and fixed on a splint. The object of the pressure on the main ves- 
sel was to diminish, not arrest, the flow of blood through it. On the eighth 
day there was again some oozing. Pus had accumulated among the muscles 
of the calf (one great objection to using pressure on the orifices of gunshot 
wounds), and required incision for its evacuation. On the ninth day a pulsat- 
ing tumour was observed on the external aspect of the leg, and next day the 
bleeding returned from both wounds. 

I wished then to cut down and tie the vessel in the wound, but a consultation 
decided on waiting a little longer, in the hope that the bleeding might not re- 
turn. On the night of the eleventh day most profuse hemorrhage recurred. 
The attendant, though strictly enjoined, failed to tighten the tourniquet, but 
the necessary steps to arrest the bleeding were taken by the officer on duty. 
Next morning, when I first heard of the occurrence, I found the patient 
blanched, cold, and nearly pulseless. A consultation decided that the state of 
the parts made the securing of the vessel in the wound very problematical, and 
that as the limb would not recover if the main artery was taken up, amputa- 
tion must be performed so soon as he had sufficiently rallied. When reaction 
had fairly taken place, I amputated the limb. The removed parts were much 
engorged, sloughed, and disorganized. The anterior tibial was found to have 
been opened for about an inch shortly after its origin, and on it was formed 
the aneurism, which had a communication with both orifices of the wound. 
The artery should have been tied in the wound on the occurrence of the second 
bleeding. I say the second bleeding, as it very often happens that even when 



250 



Progress of the Medical Sciences, 



[July 



hemorrhage has taken place, to a considerable extent, and evidently from a 
vessel of large calibre, it never recurs. Many most striking instances of this 
have come under my notice. But though more than even this is true, and that 
frequently blood thrown out repeatedly is spontaneously arrested, still the 
great preponderance of cases in which it recurs in dangerous repetitions and 
quantities, as in the above instance, should cause us, I believe, to interfere on 
its second appearance, if it be in any quantity more particularly, and that we 
should not delay, so as to run the risk of such a return as will cause exhaustion. 
Not to interfere unless the vessel is bleeding, must not always be understood 
too literally, or we will often be prevented from performing a necessary opera- 
tion till our patient is beyond our help. The hemorrhage recurs over and over 
again, and the surgeon, though as near as is practicable, arrives only in time 
to see the bed drenched, and the patient and attendant intensely alarmed. 
There is at the moment no bleeding, and he vainly hopes there will be no re- 
turn ; and so on goes the game between ebbing life and approaching death, the 
loss not great at each time, but mighty in its sum, till all assistance is useless. 

The use of acetate of lead, or gallic acid, though often trusted to in these 
hemorrhages, are surgical farces — mesmeric passes along the vessels would be 
of infinitely more service. — Edinburgh Medical Journal, May, 1856. 

17. Escape of Great Vessels by their Elasticity, from Balls. By G. II. B. 
Macleod. — There is no circumstance in gunshot wounds which is more strik- 
ing than the wonderful way in which the great vessels, by their elasticity, es- 
cape from the ball in its transit. Thus bullets innocuously traversed parts 
where one would suppose a pin's head could not be placed, without wounding 
a vessel. True, the fact that such cases remain to be seen, results from the 
vessel not having been opened, and we do not know in how many cases the re- 
sult was not so fortunate, but still, viewed merely as happy escapes, they are 
curious and interesting. In the course of the femoral vessels, this phenomenon 
is particularly common. Through the axilla, through the neck, out and in be- 
hind the angles of the jaw, between the bones of the forearm and leg, balls of 
every size often take their passage without harm to the vessels. Take the fol- 
lowing cases as examples : A soldier was wounded at Inkerman, by a ball 
which entered through the right cheek and escaped behind the angle of the 
left jaw, so tearing the parts that the great vessels were plainly visible in the 
wound. Three weeks after he was discharged without having had a bad symp- 
tom. A soldier of the Buffs was struck in June last, when in the trenches, by 
a rifle ball, in the nape of the neck. It passed forwards round the right side 
of the neck, up under the angle of the inferior maxilla, fractured the superior 
maxillary and malar bones, destroyed the eye, and, escaping, killed another 
man who was sitting beside him. This man made a recovery without a bad 
symptom. 

A French soldier at the Alma was struck obliquely by a rifle ball, near, but 
external to the right nipple ; the ball passed seemingly right through the ves- 
sels and nerves in the axilla, and escaped behind. His cure was rapid and un- 
interrupted. Endless numbers of similar cases may be seen in any military 
hospital. — Ibid. 

.18. The Warm Bath in the Treatment of Wounds, Especially those made in 
Amputation. — M. Langenbeck, of Berlin, has published in .the Deutsche Klinik 
for September 15th, 1855, an account of a process by which wounds, especially 
those made in amputation, can be constantly subjected to the influence of a 
warm bath. He first examines the modes of application of cold and warm 
water, and concludes that, in many cases, these are insufficient. He relates 
the advantages which he has obtained from the use of large warm baths after 
capital operation, such as disarticulation of the shoulder-joint, excision of the 
scapula, lithotomy, etc. These baths have been employed from half an hour 
to an hour once or twice daily, not being contraindicated by traumatic fever 
and inflammation of the edges of the wound ; at a temperature of 97° Fahrenheit, 
they maintain warmth, diminish fever, heat, and the frequency of the pulse, 
calm pain, and keep the wound clear. Topical warm baths have often been 



V 



1856.] Surgery. 251 

employed by MM. Langenbeck and Stromeyer, in gunshot wounds of the 
extremities, with or without injury of the bones, before and during suppura- 
tion. Stromeyer first recommended the use of the permanent warm bath after 
the operation for vesico-vaginal fistula. 

The following is a description of the apparatus employed by M. Langen- 
beck: — 

The apparatus intended for the upper extremities consists of two oblong 
basins, of various sizes ; they are placed in a hollow of the mattress near the 
edge of the bed, so that, as the patient lies on his back, the arm may rest 
comfortably in them. The reservoir for the leg is triangular ; the base is directed 
upwards, and the apex is fixed on a board, and moves on a hinge. By means 
of a wooden structure, which works into the supporting board, and is fixed at 
the upper end, the latter can be raised or depressed at convenience. The 
whole apparatus forms a double inclined plane, on which the leg, bent at an 
angle of about 120°, rests in the water. The basin has a cover fastened down, 
with an opening at the upper part to admit the leg. The opening has a 
projecting border, on which is fixed one end of a sleeve of vulcanized caout- 
chouc, the other end embracing the thigh and leg ; in this way, the evaporation 
and cooling of the water are prevented. In the interior of the reservoir, three 
straps are fixed to hooks, so as to sustain the limb ; while two other straps pass 
over the limb and keep it in position. At the bottom of the bath is a short 
tube, with a stopcock, for removing the water. Two openings, with movable 
coverings, are made in the cover of the apparatus; one being for introducing 
water and the other for receiving the thermometer. 

Injuries of the knee, and the stump after amputations of the thigh, require 
the horizontal position, and consequently another form of apparatus. This 
consists of a square zinc box, from half a yard to a yard in length, fourteen 
inches wide, and arranged internally in the same manner as the apparatus 
already described. For stumps, the wall which looks towards the thigh has a 
large hole, with a projecting border, to which, by means of an iron ring, a 
caoutchouc tube passes and embraces the thigh. For injuries of the knee, the 
India-rubber tube is first applied to the thigh ; then the leg is passed through 
the openings in the box and the lower caoutchouc tube ; the lower border 
of the tube fixed on the thigh is then fastened by an iron ring, which is brought 
together by screws, to the projecting rim of the opening in the basin; and the 
apparatus, being thus adjusted, is filled with water. 

M. Langenbeck, as a rule, leaves large wounds without dressings. But when 
they are the result of recent opperations, attended with loss of substance, he 
applies charpie and a bandage to obviate secondary hemorrhage. These appli- 
cations, however, are removed the next day, without disturbing the limb. In 
amputations, resections, etc., sutures are employed, an aperture being left at 
one corner of the wound for the escape of secretions. 

In general it is best not to employ the apparatus until the risk of secondary 
hemorrhage has ceased; for instance, in amputation, not within eighteen or 
twenty-four hours. In several cases, however, M. Langenbeck has applied the 
bath immediately after operation, before the patient had recovered from the 
effects of chloroform. This proceeding has the advantage of not being troubled 
by dressings, and the pain in the wound is rendered very trifling. If consecu- 
tive hemorrhage arise, the limb must be removed from the apparatus. 

Great attention must be paid to the caoutchouc bands, so that they may 
neither compress the limb too tightly, nor allow the escape of water. Notwith- 
standing these precautions, oedema and gangrene may be produced, even by 
the slightest constriction, in some cases ; especially over such parts as the crest 
of the tibia, where the bone is immediately under the skin. These inconve- 
niencies may possibly be removed by further improvements ; but it is well to 
examine the wounds carefully twice a day, when the water is renewed, and to 
shift the position of the caoutchouc sleeves, which should be sufficiently long. 

The temperature of the water must vary according to the indications, whether 
it be desired to relieve pain, to prevent consecutive hemorrhage or inflamma- 
tion, or to favour granulation. Further observations will probably point out 
the modifications required by the kind of lesion, and by the strength, age, and 



252 



Progress of the Medical Sciences. 



temperament of the patient. When the apparatus is used immediately after 
operation, the temperature employed at first is from 50° to 55° Fahrenheit; if the 
water be not renewed, the temperature rises, in from three to twelve hours, up to 
59°, 68°, or 88. After the first day, this temperature is the most agreeable to 
the patient ; at a later period when the wound begins to suppurate, water at 
93° or 95° is used. In general, the feelings of the patient are the best guide 
on this point. It is easy to keep the temperature almost constant, by covering 
the apparatus more or less, and by adding warm or cold water. In summer, 
at a temperature of from 72° to 77° in the room, the heat of the bath rose, in 
twelve hours, from 93° to 95° or 100°. On the other hand, in winter, the tem- 
perature of the room being 63.5°, the water fell nearly constantly to 86° or 88° 
in the same period. 

In general, it is sufficient to renew the water twice a day. If there be a 
large wound, or abundant suppuration, the apparatus must be carefully 
cleaned every day, by drawing off the water, and wiping the walls of the bath 
with sponges dipped in a chlorinated solution, taking care not to disturb the 
wound. When, however, the wound is large and not dependent, it is advis- 
able to pass a stream of water into it to remove the secretions. 

The advantages of this procedure are thus pointed out by M. Langenbeck : — 

1. Diminution of the Pain following Operation. — However large the wound 
may be, pain is not complained of. In two cases, after injuries of the extremi- 
ties, pain was produced in the sound foot and hand which were placed in the 
water, probably by distension of the thick epidermis. This pain, however, soon 
disappeared. When the water is being changed, and the injured part is 
exposed to the air, a cold sensation is experienced, attended with pain, which 
is removed as soon as the water is again poured in. If the wound remains 
exposed for a quarter of an hour, rigors are produced. M. Langenbeck has 
never seen rigors follow important operations, when the patient has been placed 
in a bath during anaesthesia. 

By the use of the bath, the necessity for bandages, plaster, etc., is removed. 
The sutures can be removed without disturbing the limb, and cleanliness is 
maintained. Unfortunately, in amputation of the thigh, the apparatus is 
likely to produce oedema. This objection, however, may be removed by further 
improvement. 

2. Diminution of Fever. — The traumatic fever, and that attending suppuration, 
lose their intensity. The pulse is usually from 88 to 90 ; at first, it is commonly 
as high as 120, but sinks as soon as suppuration commences. When the water 
is removed, the pulsation increases from 10 to 24, and again decreases when 
the water is added. If there be violent inflammation of the wound, or 
phlegmon of cellular tissue, the pulse may rise to 120 or 150, with correspond- 
ing general heat. During suppuration, Langenbeck once only observed rigors, 
indicating the formation of a large purulent deposit. 

3. Removal of the Secretions. — So long as the water has free access to the 
wound, the stagnation and decomposition of its secretions are impossible, in 
proportion to the fluidity of these, and the dependent position of the limb. In 
deep and sinuous wounds, as after resection of the knee-joint, injections must 
be used. Complicated wounds, as those attending fracture of the thigh, with 
injury of the knee-joint, must be carefully watched; for, even though the sur- 
face of the wound be clean, there maybe deposits in the subcutaneous cellular 
tissue, and when the wound is small, or when phlegmonous inflammation has 
set in. Incisions must then be employed, as in the ordinary treatment. 

4. Promotion of the Healing Process. — M. Langenbeck has not yet been able 
to determine how far the use of the bath promotes union by the first intention. 
In one case, however, of circular amputation of the leg immediately below the 
knee, the wound healed by the first intention in the course of the sutures. In 
an open wound, subjected to the influence of the bath, the layers of coagulated 
blood, adherent to the wound, lose their colour; the fibrin remains, until, on 
the third or fourth day, it is removed by the granulations. The surface of the 
wound, in five or eight hours after operation, assumes a yellowish-gray colour, 
somewhat white, resulting from the decoloration of the superficial parts, and 
from the layer of exudation, which adheres to the wound. The limb, especially 



1856.] 



Surgery. 



253 



in the vicinity of the wound, swells from the imbibition of water, and regains 
its natural dimensions on the removal of the water. This absorption must 
have a beneficial influence in promoting removal of the secretions, and prevent- 
ing disorders in the capillary circulation. M. Langenbeck has observed 
inflammation of the edges of the wound and phlegmonous redness only in 
cases where purulent deposits were formed, or where the sutures were too tight. 

In three or four days, the dead layer is removed in portions by the water, 
and granulation commences. In a very hort time, the deeper parts become 
filled up, the ends of the bones are covered, and the granulations from the 
medullary canal unite with the others. In the bath, the granulations attain a 
development, which is not observed with other modes of dressing. Their semi- 
transparent appearance shows that this depends in part on the absorption of 
the water. When the wound is covered with granulations, cicatrization com- 
mences. This is probably somewhat retarded by the bath; hence at this stage 
M. Langenbeck has recourse to the ordinary dressings. 

To ascertain whether wounds heal more rapidly under water than when 
exposed to air, a large number of comparative experiments would be required ; 
and even then we must remember that the period of healing varies even for the 
same operation. In three cases of subcutaneous resection of the tibia and fibula, 
healing took place in five, seven, and twelve weeks ; while in two cases of 
subcutaneous excision of ankylosed elbow-joints, the wounds healed in the 
water bath in four weeks. A case of excision of the knee-joint, performed at 
Kiel, required fourteen weeks ; while another case, under the influence of the 
bath, required only eight weeks. It must be remembered, however, that 
operation wounds sometimes heal very rapidly under the ordinary treatment, 
Nevertheless, M. Langenbeck is inclined to believe that the use of the bath 
promotes cicatrization. 

Will the employment of the bath obviate the danger of pyaemia? This 
question cannot yet be decidedly answered; but M. Langenbeck has never seen 
pysemia attend this treatment, although it occurred at the same time in other 
patients under his care. Chilling of the wound, retention and decomposition 
of the secretions, and miasmata, are the causes of pyaemia. These are obviated 
by the use of the bath ; although the possibility of the occurrence of pyaemia 
cannot be denied. 

M. Langenbeck relates several cases in which he has employed the treatment 
described, viz: — 

1. Compound comminuted fracture of the right leg: 2. Osteosarcoma of the 
right tibia; amputation immediately below the knee: 3. Carcinoma of the 
foot; amputation by Lisfranc's method: 4 and 5. Ankylosis of the right 
elbow; subcutaneous resection : 6. Medullary cancer of the patella; removal 
of the patella, and excision of the ends of the bones: 7. Large fibrous tumour 
on the outer side of the knee; extirpation; joint opened; extensive gangrene 
and sanious suppuration. Recovery took place in all the cases except the last. 

In the Deutsche Klinik for October 13, 1855, Dr. Fock publishes some further 
observations. The following are the cases in which the use of the bath is 
indicated: 1. All large wounds of the soft parts, whether it be desired to heal 
them by the first intention or not. 2. Penetrating wounds of the joints. 3. 
Compound fractures, as soon as inflammation and suppuration of the skin and 
cellular tissue set in. 4. Lacerations of the soft parts of the hands and feet, 
with or without injury of the bones. 5. After lithotomy, urethrotomy, opera- 
tion for hernia, removal of uterine tumours, extirpation of the ovary. 6. 
Caries. 7. Whitlow, diffuse phlegmon, and acute suppurative oedema. 8. 
Gangrene. 9. Burns. 10. Acute and chronic inflammation of the joints. 11. 
Operations for ankylosis and contracted joints, whether by rupture or osteology. 
[12. The Caesarean section?] — Association Med. Journ., March 8, 1856. 

19. Surgical Uses of Glycerine. — In our preceding No. (p. 518), we noticed 
some observations made by M. Demarquay on the surgical applications of 
glycerine. Since M. Demarquay published his remarks, further experiments 
have been made on the subject, the result of which has been published (Gazette 
No. LXIIL— July 1856. 17 



254 



Progress of the Medical Sciences. 



Medicate de Paris, January 26, 1856) by M. Lutton. He describes first the 
physical, and then the therapeutic effects of glycerine. 

1. Physical Effects. — Being of an oily appearance, while it is of the consist- 
ence of syrup, it prevents the dressings from adhering to the wound; and by 
its solubility in water, it allows the wounds to be readily cleaned. Glycerine 
evidently moderates suppuration ; and on the other hand, being very hygro- 
metric, it keeps the parts constantly moist, and prevents the products of 
exudation from concreting. To obtain this result, it is necessary to apply the 
glycerine in abundance, and to impregnate the charpie and linen well with it. 
It protects the parts from the action of the air, and maintains them at a 
sufficiently high temperature. In these respects, glycerine is superior to fatty 
matters for surgical dressings. 

2. Therapeutic Uses. — The first effect of the application of glycerine is to 
produce a slight prickling sensation, which, however, is soon calmed, and is 
never very distressing. 

Simple Wounds. — In ordinary wounds, whether accidental or surgical, and 
free from complication, glycerine has no very manifest action. Under its 
application, wounds heal at least as soon as under most neutral local applica- 
tions, and almost the only circumstance of any note is the small amount of 
suppuration. Besides this, there is scarcely ever an exuberance of granulations. 

Burns. — In different degrees of burns, glycerine is a very convenient and 
efficacious application. Patients who have been treated by the transcurrent 
cautery, on account of white swelling, sciata, etc., have objected to be dressed 
with glycerine, on the ground that the burn healed too quickly, and did not 
" draw" enough. The happy effect of glycerine has been remarkably observed 
in a case of burn in the second degree, produced by an explosion in a mine. 

Diphlheritis of Wounds. — In the Hospital of St. Louis, wounds, during the 
first days of their production, present a grayish, almost diphtheritic appearance, 
and become clean slowly. Under the influence of glycerine, this condition, 
more troublesome than serious, is arrested ; the wound assumes a rosy aspect, 
without any exuberance of granulations. 

Hospital Gangrene. — It was for this affection that glycerine was first employed 
in the Hospital of St. Louis. The disease in the first case was very extensive, 
and had been unsuccessfully treated by lemon-juice, quinine, and even by 
strong nitric acid and the actual cautery. In this, as in two other cases, 
glycerine was completely successful. 

Abscesses and Purulent Deposits. — In deep wounds and sinuous ulcers, 
glycerine has been used, either by being introduced on a piece of charpie, or as 
an injection. The amount of suppuration has been remarkably diminished, 
and the period of cicatrization has been smaller. M. Demarquay has also 
injected glycerine into cold and congestive abcesses, and those in connection 
with inflamed bones, with complete success. 

Ulcers. — Chronic, varicose, gangrenous, and other ulcers, have become rapidly 
clean under the influence of glycerine. The surface throws out granulations, 
and cicatrization soon takes place. Rest is a powerful and necessary aid. 

Chancres. — Glycerine though it has no specific action on chancres, rapidly 
cleans the surface, and causes them to assume a healthy appearance. 

Diseases of the Keck of the Uterus. — MM. Trousseau and Aran have already 
employed glycerine, but with little satisfaction, in uterine affections. M. De- 
marquay, however, has found it useful in simple or granular ulceration of 
the cervix. When the ulceration has been chronic, or when the cervix was 
rather enlarged and tumefied, caustic applications were also made. Glycerine 
was then applied by means of wadding : after the separation of the eschar, the 
secretions, commonly so abundant and fetid, were remarkably moderate in 
quantity. 

In vaginitis, also, glycerine has been applied; but here, as in diseases of the 
cervix uteri, nothing conclusive can as yet be arrived at regarding its efficacy. 

The editor of the Med. Times and Gaz. states (April 22, 1856) that he has lately 
had an opportunity of watching a trial of the remedy by Mr. Skey, in St. Bar- 
tholomew's Hospital. The first few cases in which it was resorted to appeared 
greatly benefited, and Mr. Skey was induced by their result to direct its general 



1856.] 



Surgery. 



255 



use. His final conclusion, however, as stated in clinical remarks, has been, that 
the remedy possesses no peculiar virtues whatever. A considerable number of 
sores heal rapidly during its use, as, indeed they would do under that of any 
non-irritating application which would exclude the air and prevent drying; 
in those, however, which have assumed an unhealthy state, and which resist 
the influence of other like remedies, it effects nothing whatever. A smaller 
series of trials by Mr. Hutchinson on patients at the Metropolitan Free Hos- 
pital, have led him to the same conclusion with Mr. Skey. Unhealthy sores 
dressed with it for periods of three weeks have remained precisely in statu quo. 
It is an agreeable application, causes no smarting, excludes the air, keeps the 
sore moist, and does not adhere to its edges ; but beyond these it appears to 
possess no recommendations. While more expensive, it seems little, if at all, 
superior to olive or almond oil. It may seem difficult to reconcile the great 
discrepancy between foreign and English experience which these conclusions 
show. It might, perhaps, scarcely be deemed fair to insinuate, that on the 
Continent the employment of dressings which simply exclude air, and are them- 
selves non-irritating, is not so well understood as among ourselves, and that, 
consequently, credit has been given to a single remedy which belongs rather 
to the whole class. Such, however, we suspect is, to some extent, the case. 
In one case, recorded by M. Petel, the source of fallacy is transparent. A 
woman came under his care for phagedaenic stomatitis. Glycerine was applied, 
and chlorate of potash given. A very rapid cure, of course, occurred. The nar- 
ration reminds one of Voltaire's assertion, that he could easily kill a flock of 
sheep by spells of witchcraft, provided, at the same time, he might mix a little 
arsenic with their food. 

20. New Method of Treating Phagedena. — Mr. Cock has recently been trying, 
in Guy's Hospital, a plan of treating phagedenic ulcers by constant irrigation. 
The method is, to have the sore well exposed, and the affected limb placed on. 
some waterproof material; a reservoir above the bed is then filled with luke- 
warm water, and, by means of an elastic tube, a stream is kept continually 
flowing over the surface of the sore. By this means all particles of discharge, 
etc., are washed away as soon as formed, and the ulcer assumes the clean, pale 
appearance of a piece of meat which has been long soaked. In all the cases 
in which it has been practicable to employ the irrigation efficiently, a speedy 
arrest of morbid action has been secured, and the number has included several 
in which the disease was extensive and severe. The theory of the treatment is, 
that phagedenic action is a process of local contagion — the materies morbi by 
which the ulcer spreads being its own pus. Admitting this supposition — 
which there is every reason for doing — to be true, the object to be kept in view 
in curative measures is either to decompose or to remove the local virus. This 
end is accomplished somewhat clumsily by such remedies as the nitric acid, 
which, unless so freely used as not only to char up all the fluid matters, but to 
destroy the whole surface of the ulcer to some depth, fails to prevent a recur- 
rence. Mr. Cock's plan of subjecting the ulcer to a perpetual washing attempts 
the accomplishment of the same end by a more simple and direct method. It 
involves no pain to the patient, and does not destroy any healthy tissues. Its 
one disadvantage seems to be, that, excepting on the extremities, its use would 
be attended with some inconvenience, from the difficulty of preventing the water 
from running into the patient's bed. Should, however, further trials confirm 
the very favourable opinion which has been formed at Guy's as to its value, 
these difficulties might, no doubt, be surmounted by the contrivance of suitable 
apparatus. The directions as to temperature of the water are that it should 
be as warm as comfortable to the feelings of the patient; and, as preventive of 
smell, Mr. Cock advises the addition of a small quantity of the chloride of 
lime or of soda. — Med. Times and Gaz., April 12, 1856. 

21. Is it always necessary to resort to Amputation when a Limb is attacked with 
Sphacelus ? — Prof. Bardixet, of Limoges, has brought this important question 
before the Academy of Medicine of la Haute Vienne, and has answered it ia 
the negative. 



256 



Progress of the Medical Sciences. 



[July 



We are too ardent partisans of conservative surgery, having ourselves suffi- 
ciently often protested against the excessive tendency to operate everywhere 
and at all times, not to hasten to submit to our readers the reasons adduced 
by M. Bavdinet in support of his opinion. 

The following is the re'sume' of his memoir : — 

1st. In this memoir I report eight new cases of sphacelus (two of the finger, 
three of the forearm, and three of the leg), in none of which amputation was 
performed. The task of eliminating the dead parts was intrusted to Nature, 
except that her operations have been actively aided by the employment of 
the ordinary disinfectants, and especially by the early resection of the dead 
parts near the eliminatory circle. 

In these eight cases recovery took place. 

Had amputation been performed, it is, on the one hand, extremely pro- 
bable that a certain number of patients would have died ; on the other, several 
of them would have been deprived, in consequence of the necessity of ampu- 
tating above the eliminatory circle, of a portion of their limbs (the knee, for 
example, or the upper part of the forearm), which they are fortunate in having 
been able to preserve. 

It is, therefore, not always necessary to amputate in cases of sphacelus. 

2d. We should, above all, be extremely cautious in having recourse to ampu- 
tation in cases of spontaneous gangrene — first, because in such cases, whatever 
we do, and even after the establishment of the eliminatory circle, we can never 
be sure that the gangrene will not reappear, and that we shall not thus need- 
lessly add the pain and dangers of a serious operation to those of the original 
disease. 

3d. Because the fear of amputating in parts whose vessels are diseased, 
obliges us to carry the section up to a considerable height, and thus involves, 
sometimes very uselessly, the sacrifices of parts which might have been pre- 
served, and the loss of which is to be lamented. 

4th. Because the gangrene may attack several limbs in succession, and even 
all the limbs, of which I have quoted two examples, and we should then find 
ourselves compelled to perform a series of sad mutilations. 

5th. Because, on the contrary, in confining ourselves to cutting away the 
dead parts near the circle of elimination, we perform an operation which is 
always practicable and always useful, as it liberates the patient from a focus 
of infection. 

6th. Because we avoid the risk of performing an amputation, all the benefits 
of which will be lost if the gangrene makes fresh advances. 

7th. Because, in adopting the new mode, Ave do not unnecessarily remove 
parts which the patient is much interested in preserving. 

8th. Because we have still the power of performing amputation, if it should 
become necessary. — Dublin Med. Press, April 9th, 1856, from Presse Medicate 
Beige, March 23, 1856. 

22. Practical Deductions from a Clinical Record of Twenty-six Cases of Stran- 
gulated Femoral Hernia. — Mr. Birkett, in a paper read before the Medical 
Society of London (April 26th, 1856), commenced by stating that the object of 
the paper was, first, to bring prominently into the foreground the causes of 
death; 2d, The circumstances by which those causes are brought about; and, 
3d, The means by which they may be avoided. It was shown, by means of a 
table of the cases, that a certain number of unfavourable circumstances occur- 
red in each case, and that, in proportion to the aggregate, as a general rule, 
the case was cured, or terminated fatally. But in some of the cases only two, 
three, or four unfavourable circumstances existed, and yet the patients died; 
and in these, as well as others with a larger number, the causes of death were 
sought for and demonstrated. Of the twenty-six cases, all of which were ope- 
rated upon by the author, one-half terminated fatally. In the fatal cases, death 
resulted from causes over which the operation could have but little influence ; 
and it was undertaken only with the view to place the patient in a condition 
more favourable to recovery. The causes inducing the fatal result may be thus 
enumerated : — 



1856.] 



Surgery. 



257 



1. The consequences of a journey performed while the patient was suffering 
with strangulated femoral hernia. 

2. The defective constitutional nutrition of the patients generally. 

3. Irrecoverable prostration, the result of long-continued vomiting and stran- 
gulation of the bowel in aged women. 

4. Violence inflicted on the hernia. To this cause, the death of not less than 
five out of the thirteen is to be attributed. 

5. The administration of purgatives before the operation. 

The author unhesitatingly preferred to reduce the hernia without opening 
the peritoneal sac in those cases in which the surgeon would be justified in 
returning the protrusion by the taxis, if it could be accomplished. 

In the twenty-six cases, the peritoneal sac was opened in twelve, and the 
causes which prevented the reduction of the hernia without so operating were 
the three following: — 

1. The contents of the sac. 

2. The morbid condition of the contents of the sac. 

3. The dimensions of the neck of the sac, and the unyielding state of its 
tissues. 

Six cases were related in which the author had reduced the hernia by a 
simple division of the fibrous tissues about the neck of the sac, and external 
to that covering of the hernia known as the fascia propria. To this simple 
method of relieving the constriction around the bowel the author gave the 
name of "The Minimum Operation/-' The causes of death in the fatal cases 
were shown, by post-mortem examination, to be referable to peritonitis, injury 
of the bowel inflicted in the taxis, exhaustion after fecal fistula, phlegmonous 
inflammation, collapse, acute bronchitis, and perforation of the bowel. Of the 
cured cases, the minimum of hours during which the bowel was strangulated 
was three hours ; the maximum was seventy-seven hours. Of the fatal cases, 
the minimum period of strangulation of the bowel was eleven hours, the maxi- 
mum seventy-nine hours. Of the cured cases, the average number of hours 
during which the bowel was strangulated amounted to twenty-three. Of the 
fatal cases, the average period of strangulation of the bowel was forty-six 
hours. The causes of death were primary and secondary: 1. Prostration; 
peritonitis; gangrene of the intestine; perforation. 2. Bronchitis; abscess 
behind the peritoneum; phlegmonous inflammation and suppuration. The 
circumstances by which they were brought about: Age ; a journe}^; the defect- 
ive constitutional nutrition of the patient; the morbid state of the canal above 
the strangulated piece of bowel; injury of the hernia caused by the constric- 
tion of the ring, and by manual violence inflicted on it; the duration of the 
sufferings; the intensity of the constitutional sympathies; fecal fistula; neglect 
of the tumour; the administration of purgatives; the warm bath. The means 
by which they may be avoided are: By care in manipulation ; the early relief 
of the bowel from constriction ; the reduction of the hernia without opening 
the peritoneal sac ; the exhibition of opium, and the avoidance of all causes 
likely to induce exhaustion. — Med. Times and Gaz., May 3, 1856. 

23. Mode of Reducing Strangulated Hernia, after Failure of the Taxis, by a 
Bloodless Operation. — M. Seutin, the eminent surgeon of Brussels, is endea- 
vouring to establish, in a Belgian Medical journal, the superiority of tearing 
either the inguinal or crural ring, over incising the same, for the reduction of 
strangulated hernia. He quotes experiments on the dead body, and several 
successful cases ; and is confident that his method will soon supersede the ope- 
rative measures generally resorted to. He places, first, great reliance on 
graduated taxis continued with due precautions for a considerable period ; and 
when this fails, he endeavours to hook his index-finger round the margin of 
the ring, by passing it between the tumour and the abdomen ; and by using a 
certain force, he causes the fibres of the external oblique to give way and crack 
to an extent sufficient for the reduction of the hernia. M. Seutin defends his 
practice with considerable ability, and hopes trials will be made. — Lancet, 
April 26, 1866. 



258 



Progress of the Medical Sciences. 



[July 



24. Radical Cure of Hydrocele. — A man, aged 31, has recently been under 
Mr. Lloyd's care, in St. Bartholomew's, on account of a hydrocele, which had 
been several times tapped, and on one occasion treated by the injection of 
iodine, Avith the hope of permanent cure. The latter expedient, however, had 
failed, the sac having refilled. Mr. Lloyd adopted a plan, which has long been 
a favourite with him, of introducing a little of the red precipitate into the sac. 
The fluid having been drawn off by a canula, large enough to allow a director 
to enter it, the latter instrument, oiled, and then dipped in the powder so as to 
carry a few grains adhering to it, was introduced and moved about in the cavity. 
The introduction was repeated two or three times; some inflammation followed, 
and a perfect cure ensued. The practice has the advantage over that by in- 
jection of not requiring any special apparatus. Mr. Lloyd believes it also to 
be more uniformly successful. — Med. Times and Gaz., April 12, 1856. 



OPHTHALMOLOGY. 

25. Anemic Protrusion of Eyeball. — Robt. Taylor, Esq., Surgeon to the Cen- 
tral London Ophthalmic Hospital, relates [Med. Times and Gaz., May 24th, 1856) 
the following cases, illustrative of a disease which has only within a recent 
period attracted attention, and the true pathological explanation of which is 
yet a desideratum. 

" Case 1. — Mrs. T., aged 26, has been married eight years, but has never 
been pregnant. Her menstrual periods have been regular ; but the discharge 
has always been in excess, and she has had several attacks of menorrhagia, 
losing much blood on each occasion. She has long been subject to leucorrhoea, 
which, six months ago, became very profuse, and shortly after this she was 
attacked with palpitation of the heart. About the same time she observed a 
swelling in her throat, and her eyes became so prominent as to attract the at- 
tention of her friends. These symptoms, which appeared as nearly as possible 
simultaneously, have gone on increasing slowly but steadily. Leeches and 
tincture of iodine have been applied to the throat, but without producing any 
diminution in the swelling. 

Present State. — She is very pale and feeble. She suffers from spinal tender- 
ness, intercostal neuralgia, ringing in the ears, oedema of the ankles, and other 
symptoms of anaemia. She is exceedingly nervous, starting and trembling 
violently when suddenly addressed ; she has occasional hysteric fits. The pul- 
sations of the heart average 134 per minute, and are very distressing; the 
carotid arteries also throb violently. The thyroid gland is enlarged to about 
three times its natural size, its surface being smooth and regular ; several of 
its enlarged arteries can be felt pulsating near the surface. The eyeballs pro- 
trude so as to expose a broad rim of the sclerotica around the margin of the 
cornea, giving her a wild and staring appearance, which attracts attention and 
exposes her to annoyance in the streets. The amount of protrusion varies, 
within certain limits, with the degree of nervous excitement, being always 
much greater when she is agitated. The eyeballs can be readily replaced by 
gentle pressure, but they speedily resume their prominence when the pressure 
is remitted. There is some congestion of the conjunctival vessels, and slight 
increase of the Meibomian and mucous secretions ; in other respects the eyes 
have a healthy appearance ; their movements are perfect in every direction, 
and the sight is unimpaired. The eyelids, which are of a dusky colour, cannot 
be closed without a slight muscular effort. 

The treatment, which extended over a period of three months, consisted in 
the administration of iron in several forms; astringent injections, per vaginam, 
to check the leucorrhoea ; and belladonna plasters over the region of the heart, 
which afforded great relief by diminishing the violence of the palpitation. As 
her general health improved, the heart's action approached more and more to 
the natural standard, and the prominence of the eyeballs was reduced, until 



1856.] 



Ophthalmology. 



259 



they ultimately resumed their proper position ; but no change took place in the 
size of the thyroid gland, so long as she remained under observation. She 
subsequently had a slight relapse, brought on apparently by mental agitation, 
but a similar plan of treatment again proved successful in a few weeks. 

Vase 2. — Mrs. C, aged 40, has had eight children, the last two of whom were 
twins, and were born four years ago. One of these she suckled for twelve, and 
the other for sixteen months ; during which time, as on previous similar occa- 
sions, she menstruated regularly and abundantly. When she had suckled both 
infants for a year, she first observed an enlargement of her throat, and the 
swelling increased slowly for about two years, since which it has remained 
stationary. Some months after she first observed this enlargement her eyes 
began to protrude, so as to attract the attention of her friends. She then ap- 
plied to a surgeon, who told her that she had disease of the heart — a fact 
which she then learned for the first time, as she had never felt the slightest 
uneasiness in that region ; how long the palpitation may have existed it is im- 
possible to say, as even now, although it is very violent, she is quite unconscious 
of it, unless when much excited. 

Present State. — Pale, anemic, and highly excitable. The eyeballs protrude 
so as to expose a narrow rim of sclerotica around the cornea. They can be 
readily replaced by gentle pressure ; their movements are perfect in every 
direction, and the vision is unimpaired. The protrusion varies with the amount 
of nervous excitement. The conjunctivse are slightly injected, but in other 
respects the eyes appear to be perfectly healthy. The heart beats violently 
and rapidly, the pulsations being 142 per minute ; but it is probable that this 
exceeds the usual standard, and is partly due to excitement, consequent on a 
stethoscopic examination. The carotid arteries pulsate strongly and visibly. 
The thyroid gland is enlarged, chiefly in a lateral direction, to more than thrice 
its natural size ; its surface is smooth and regular. 

The treatment was conducted upon the same general plan as in the preced- 
ing case, and extended, with one or two interruptions, over a period of five 
months. The general health was restored, and the eyes resumed their natural 
position ; but there was not any diminution in the size of the goitre. 

Case 3. — Mrs. R., aged 26, has been married nine years, but has never been 
pregnant. For many years she has been subject to profuse leucorrhcea, and 
her health has been still further impaired by insufficient nourishment, and by 
close application to needlework. Two years ago, she began to suffer from pal- 
pitation of the heart, and soon after this her throat became enlarged, and her 
eyeballs unnaturally prominent. 

Present State. — Pale, thin, and excessively nervous and excitable, trembling 
almost convulsively when suddenly spoken to, or even when looked at. The 
eyes protrude to such an extent that she cannot, by any effort close the eyelids, 
and she complains much of the discomfort caused by their remaining half-open 
during sleep. The eyeballs can be replaced by gentle pressure ; their move- 
ments are perfect, and the sight unimpaired. The protrusion varies consider- 
ably, with the amount of nervous excitement. The conjunctivas are somewhat 
congested ; in other respects the eyes appear perfectly healthy. The thyroid 
gland is enlarged to about four times its natural size, and numerous dilated 
arteries can be felt near its surface - , which is smooth and regular. The heart, 
under the agitation of being examined, beats violently, the pulsations being 
144 per minute. The carotid arteries also throb visibly. 

This patient remained under treatment for two months, the remedies em- 
ployed being iron, astringent injections per vaginam, and belladonna plasters 
over the region of the heart. She had improved considerably in health, and 
her eyes had receded so far that she could close the eyelids without any effort, 
when she left town, and remained without medical treatment of any kind for 
some months. A short time since, she again made her appearance at the hos- 
pital, in nearly the same condition as at her first visit. The treatment has been 
resumed, and she is again progressing favourably. 

In each of the above cases, a careful stethoscopic examination of the chest 
was made by my friend Dr. Hare, who has kindly permitted me to condense 
and make use of his report. 



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[July 



In the first there was some hypertrophy, with a little dilatation of the heart, 
but no valvular disease. In the second, the condition of the heart was almost 
exactly similar, but there was a doubtful murmur with the first sound, the 
exact nature of which could not be clearly ascertained, on account of the ex- 
cited state of the circulation at the time. In the third, there were slight hyper- 
trophy and dilatation, with a distinct, though not loud systolic murmur at the 
base, ' which/ Dr. Hare says, 1 may be anemic/ 

Case 4. — I have reserved this case for the last, although it is the first entered 
in my case-book, as I am desirous of calling attention to a very striking pecu- 
liarity which it presented, in the sudden appearance of the exophthalmia. 

Letitia M., aged 21, was subject to fits, probablv epileptic, in childhood. 
These gradually ceased as she attained the period of puberty, but she remained 
excessively nervous and hysterical, and has long suffered from spinal tender- 
ness, intercostal neuralgia, coldness of the extremities, and other symptoms of 
nervous debility. Three years ago, after a fall by which she severely bruised 
her right side, she began to suffer from palpitation of the heart ; this has con- 
tinued ever since, being constant and annoying, interrupting her sleep, and 
greatly aggravated by the slightest agitation or exertion. One year after this, 
the thyroid gland began to enlarge, and gradually increased until it attained 
its present volume, about four times that of the healthy gland. She was for 
some time under hospital treatment for this, as well for the palpitation, but 
without receiving any benefit. About a week before I first saw her, she felt 
an unusual sensation in the brows one morning on awaking, and on looking in 
the mirror, she found that her eyes, which had been perfectly natural in ap- 
pearance when she retired to rest, were protruded to such an extent that she 
could scarcely close the eyelids. 

Present State. — The eyeballs protrude, as above described : their movements 
are perfect; the sight is not impaired, and they appear to be perfectly healthy. 
They can be readily replaced by gentle pressure, but resume their abnormal 
position when the hand is removed. She says that the prominence varies very 
much, and that at times it is scarcely perceptible. The action of the heart is 
very violent ; the pulsations, under the excitement of being examined, are 140 
per minute. There is a slight blowing murmur with the first sound ; on per- 
cussion, the dulness over the heart is rather more extensive than natural. 
The carotid arteries throb violently. The enlarged thyroid gland is smooth 
and regular, and several of its dilated arteries can be felt near the surface. 

Under treatment of a similar character to that adopted in the preceding cases, 
and extending over rather more than two months, the eyes had very nearly re- 
sumed their normal position, and the general health was very much improved, 
but there was no diminution in the size of the thyroid gland. She then left 
town, and I have not had an opportunity of seeing her since. 

In addition to the above, I have collected from the various medical journals 
twenty-one cases, which have been given sufficiently in detail to render them 
free from doubt ; others are alluded to as having occurred, but without any 
particulars being given. Of the twenty-five reported cases, twenty occurred in 
females, and four in males ; in one the sex is not mentioned, but, from the con- 
text, the patient appears to have been a male. Three deaths have occurred, in 
each instance in males. In two there was a post-mortem examination. In the 
first, related by Sir Henry Marsh, the patient had long suffered from extensive 
organic disease ; there was considerable dilatation, with hypertrophy, chiefly 
of the left side of the heart, and some amount of valvular disease, chiefly of 
the right; the Tight internal jugular vein was very much dilated ; the patient 
died of general anasarca, followed by erysipelas and gangrene. In the second, 
detailed by Dr. Begbie, the patient suffered from organic disease of the heart, 
enlargement of the liver, general dropsy, and jaundice; of which complication 
of disorders he died. The heart was found to be large, soft, and flaccid ; all 
the cavities, but especially the ventricles, were dilated ; the valves were larger 
than usual, having accommodated themselves to the increased size of the cavi- 
ties ; but they were otherwise normal. The aorta, in comparison with the pul- 
monary artery, was small. The internal jugular veins were much dilated. The 
blood in the heart and great vessels was very fluid. In none of the other 



1856.] 



Ophthalmology. 



261 



cases has stethoscopic examination detected any very serious amount of cardiac 
disease ; in some there has been slight dilatation with thinning of the walls, 
but without valvular disease ; in others there does not appear to have been any 
structural alteration. 

"With one exception, the enlargement of the thyroid gland has appeared to 
be due to simple hypertrophy of its normal structures, with a great increase in 
the activity of its circulation and size of its bloodvessels. In the exceptional 
case recorded by Mr. MacDonnell, the goitre was of the cystic variety, and had 
attained a considerable size. 

In no instance has there been any disease of the eyeball. It is true that in 
a few cases it is described as having been enlarged; but this is evidently a mis- 
take, as the vision was unimpaired. The eyeball is not subject to enlargement, 
except as a consequence of long-continued inflammatory disease, destructive of 
vision, by which the tough, unyielding tissue of the sclerotica is softened, and 
gives way to the pressure from within, bulging, generally, in a very irregular 
manner. The protrusion must be due to some other cause, the nature of 
which, in connection with the general pathology of the disease, we have now to 
consider. 

It must be borne in mind that the protrusion may, as in Case 4, come on 
suddenly ; that it varies in degree according as the patient is agitated or tran- 
quil ; and that the eyeballs can be replaced in their natural position by gentle 
pressure. It cannot, therefore, be due to any solid tumour, or fluid effusion in 
the orbit; nor can it be ascribed to paralysis of the recti muscles, for the eye 
can be moved in every direction as readily as in health. The cause to which it 
is most commonly ascribed is, congestion of the deep-seated veins of the orbit ; 
and this seems to afford a more probable explanation than any other, both 
from its being quite reconcilable with the variable amount of exophthalmia, and 
from the well-known effect of impeded return of blood from the head in causing 
prominence of the eyes, as witnessed, for example, in strangulation. But how 
are we to account for this congestion ; and how are we to explain its associa- 
tion with the peculiar condition of the heart and the thyroid gland ? for the cases 
already on record are too numerous to permit us to suppose that these are 
merely coincident symptoms ; together they evidently constitute a distinct dis- 
ease, and there must be some common cause capable of producing each, and of 
rendering them mutually dependent upon each other. 

It has appeared to me, that a key to the true solution of this question has 
been given by Dr. Marshall Hall, in his valuable writings on the subject of 
convulsive and paroxysmal diseases. He has shown that, in such diseases, 
there is a tendency to spasm of the muscles of the neck ; and that the seizures 
are the direct result of impeded return of blood from the head, the deep-seated 
veins being compressed by the irregular muscular action. Now, the subjects 
of anemic protrusion of the eyeball are eminently of the class to which Dr. 
Hall's remarks apply. Some of them are subject to fits, hysterical or epileptic ; 
in all the nervous system is in a state of extreme excitability, so that the 
slightest agitation produces starting and trembling, sometimes so violent as 
almost to resemble convulsion in a minor degree. Is it not probable that, as 
in the confirmed epileptics, there may, in these cases also, be an impediment 
to the free return of blood from the head, only to a less amount, and, perhaps, 
more continuously ? In the only two post-mortem examinations that have 
been made, the internal jugular veins were found to be greatly dilated, as 
though they had long been subject to distention by some obstructing cause 
towards the lower part of their course ; and, as in neither case was there any 
solid growth by which they could have been compressed, it does not seem un- 
reasonable to suppose that the obstacle was due to muscular spasm. The same 
explanation would account for the enlargement of the thyroid gland, which, as 
has been already stated, is due to simple hypertrophy of its normal structures, 
and would be a probable result of long-continued hyperasmia. The palpitation 
of the heart does not require any explanation here, as it is common to all cases 
of anaemia, whether accompanied or not with protrusion of the eyes. 

The different stages of the disease, then, may be stated as follow : First. 
Some debilitating disease, or exhausting discharge, producing — secondly, anre- 



262 



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[July 



mia ; thirdly, that peculiar state of the nervous system, in which there is a 
tendency to spasm of the muscles of the neck; fourthly, as the result of such 
spasm, and consequent impeded return of blood from the head, hypersemia, 
and hypertrophy of the thyroid gland, and dilatation of the veins of the orbit, 
causing exophthalmia. 

This explanation I offer merely suggestively. I am well aware that it is 
open to many objections ; but none have as yet occurred to me which appear 
insuperable. It is supported by the histories of all the carefully described 
cases, and by the necroscopical appearances in the only two post-mortem exa- 
minations that have been made; and it accounts for the association of three 
symptoms, the connection of which it seems otherwise impossible to divine. If 
it fail to stand the test of rigid investigation, it may still have the good effect 
of attracting the attention of those who are able to expose its errors, and to 
substitute a perfect one in its place. 

It is unnecessary to dwell at any length upon the treatment, which is essen- 
tially that of ancemia. A few cases have occurred in which patients have been 
attacked who were already the victims of extensive diseases of the thoracic and 
abdominal viscera, and in such the treatment must be merged in that of the 
more serious disorder. But in the great majority of instances, any structural 
changes that have been detected have been comparatively slight, and amenable 
to remedial measures. The patient should, therefore, be encouraged to look 
forward with confidence to a successful issue. In the words of Dr. Begbie, 
whose valuable paper contains the latest and most complete resume of the sub- 
ject, 1 it is of great consequence to impress those suffering from this affection 
with the belief of its curable nature, and to urge upon them the persistent 
employment of the means of restoring the red particles of the impoverished 
blood, and improving the general health/ The starting point of the disease 
must first be ascertained, and in females this is almost always some form of 
exhausting discharge in connection with the uterine organs, which must be 
checked by appropriate remedies. The various preparations of iron, nutritious 
and unstimulating diet, pure air, and absence of excitement ; the treatment, in 
short, which is found successful in cases of ansemia not thus complicated, are 
the further means to be adopted. No local applications are necessary, either 
to the eyes or to the thyroid gland ; but as some patients are dissatisfied with- 
out them* they maybe directed to use the eye-douche, or to bathe the eyes with 
cold water from time to time. The only local application which I have found 
really serviceable, has been a belladonna plaster over the region of the heart, 
which, in some instances, has had a marked effect in diminishing the violence 
of the palpitation. The progress towards recovery is generally slow, and the 
treatment may require to be prolonged over many months ; but if judiciously 
selected and carefully persevered in, we may look forward with confidence to 
the restoration of the general health, and the complete disappearance of the 
deformity caused by the unnatural prominence of the eyes. 

In many of the recorded cases, the swelling of the thyroid gland has also 
subsided, but this has by no means uniformly followed ; it has occurred, so far 
as I am able to judge, more frequently in private patients, who are more under 
control, and have the means of carrying out more fully the prescribed medi- 
cinal and dietetic regulations, than in the less regular and less favourably 
situated class to which the out-patients of hospitals belong. But as the en- 
largement is rarely to any extent, and as a certain amount of diminution 
invariably takes place, the persistence of a slight and scarcely perceptible 
fulness is not a matter of any importance." 

26. Observations on Cataract. — In commenting on a case of cataract recently 
operated, Mr. Wharton Jones made some excellent clinical remarks on the 
subject of cataract generally, as the result of his experience in University 
College Hospital. The opinions expressed by the operator are corroborated 
also by the scientific observations of Mr. Bowman and Mr. Critchett at the 
Ophthalmic Hospital in Moorfields, so that they may be taken as a fair repre- 
sentation of London ophthalmic practice on the subject of cataract. 

As to the use of atropine to dilate the pupil, though this was used in the 



1856.] 



Ophthalmology. 



263 



present case, Mr. Wharton Jones, like Mr. Dixon, does not think atropine or 
belladonna necessary. If the patient be in the recumbent position, and can 
be induced to remain without making any muscular effort, that is all that is 
required. 

Next, as to the direction in which the section of the cornea should be made, 
whether upwards or downwards, though a " great deal has been said on both 
sides," Mr. W. Jones believes that one mode of operating is as good as the 
other ; and for himself, he sometimes operates in the downward direction, 
sometimes in the upward direction. The advantages of the section of the 
cornea, in an upward direction, he is inclined to believe, after some experience 
of it, are only imaginary. Something, no doubt, is due to the peculiarities of 
each case ; if the patient be excessively nervous, and, from some reflex or 
excito-motor influence, turns the eye up, it is difficult to operate in either direc- 
tion. (Mr. Wharton Jones here showed the different steps of the operation for 
cataract, by sections of the cornea in both directions, on some fresh eyes from 
the lower animals, bringing out the lens in each case with remarkable facility.) 
A great deal depends on the treatment of cases of cataract after they have been 
operated on ; it is necessary for the patient to rest with the eye closed up for 
at least three days. In the case of the man operated on in the present instance, 
it appeared that the iris, or pupil, was dragged to the side from loss of vitreous 
humour, but this did not signify; in a fortnight he could see very well; seven- 
teen days was the earliest convalescence the operator had met in a case of 
operation by the upper section, but five or six weeks is not an uncommon 
average for convalescence. Hemorrhage into the vitreous humour is one of 
the accidents to be avoided, as it is a disastrous complication of every mode of 
operative proceeding. 

Mr. Wharton Jones next referred to the two other operations, depression, 
and division of the lens, which the surgeon is sometimes called on to perform ; 
division of the lens is quite a different operation, he remarked, from depression 
or couching, so that no correct or fair comparison can be instituted between 
them. Extraction and depression, on the other hand, can be compared ; after 
extraction, as familiarly known, the best eye is procured. Yet by depression, 
though the eyesight is not so good, and we have more inflammation to guard 
against, as the depressed lens acts something like a foreign body, yet, in per- 
sons of the age of fifty years, or above that period, very great success is found 
to obtain from this operation. It must not be forgotten, however, that, espe- 
cially in gouty and rheumatic subjects, we must calculate on the dangers of 
the inflammation caused by the displaced lens attacking the retina and iris. 
Sometimes, even from other considerations, it may be advisable to have 
recourse to the operation of couching. A case was here cited by Mr. Wharton 
Jones, where he recently tried couching, for the reason that the opposite eye 
had been operated on previously in the City for extraction, but it had failed. 
He did not know the reason why — perhaps something in the patient's constitu- 
tion ; yet depression had succeeded very fairly in the opposite organ. The 
operator next made some practical observations on the character of the cataract 
glasses the surgeon should order for his patient. A four and a half focus is 
about the best ; a five may, in rare instances, be required ; but for reading, a 
two and a half glass will be necessary. — Association Medical Journal, March 
29th, 1856. 

27. Traumatic Cataract and its Treatment by Operation. — Mr. J. V. Solomon, 
in a paper read before the Birmingham and Midland Counties Branch of the 
Prov. Med. and Surg. Association, after giving an outline of the physiological 
anatomy, of the lens and its capsule, which, he said, was of interest, by throw- 
ing light upon some of the nutritional changes of which the lens is the subject, 
and as affording a rationale of certain operations which are performed for their 
cure, defined traumatic cataract as an opacity of the lens or its capsule, in 
consequence of a blow upon, or penetrating wound of the eyeball. Mr. Solo- 
mon then considered the subject under three heads. 

a. In cases of traumatic cataract, attended by little or no inflammation, 
and where the capsule having been ruptured accidentally the lens is under- 



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[July 



going absorption, his practice is to break it up ten or fourteen days after the 
accident, and clear the pupil of capsule, and so prevent the formation of a 
capsular cataract within the area of the pupil. The operation is performed by 
penetrating the cornea with a fine needle, etc. (Keratonyxis). Where the case 
is complicated by an ununited wound of the cornea, his first care is to obtain 
union by closing the eyelids with strips of plaster, and enjoining rest of the 
organ. Prior to which, any portion of recently protruding iris is returned 
within the anterior chamber by gently pressing upon it with the spoon end of 
the " curette/' whilst the patient is under the influence of chloroform : but 
when that drug is contraindicated, or lymph covers the irident tumour, it 
must be snipped off, unless it should happen to be very small, with a pair of 
sharp-cutting eye scissors. When the wound is central, belladonna is to be 
immediately applied to the brow, and a drop of atropine to the conjunctiva; 
but when such is not the case, the application must be delayed until cicatriza- 
tion has taken place. 

b. In cases where the cataract is dislocated against the back of the iris, 
or is pushing its way through the pupil, and is attended by severe ocular pain 
and inflammation, Mr. Solomon's invariable practice is to extract the lens by 
Gibson's operation, which, by removing a cause of irritation, alleviates suffer- 
ing, and accelerates recovery. In the event of these cases being treated only 
by the ordinary means applicable to internal inflammation of the eyeball, all 
the symptoms are protracted, and the pupil remains small, and obstructed by 
thickened opaque capsule, or organized lymph. Moreover, the deep seated 
structures are prone to be affected by inflammatory disorganization. In a 
word, the eye is left, on the subsidence of the ophthalmia, in a very unfavour- 
able condition for any operation that may be at any time undertaken with the 
intention of clearing the pupillary aperture; unless the canula scissors can be 
made of use. It is in this class of cases that chalky or bony material forms 
withing the capsule. 

c. With regard to cases of single traumatic cataract, occurring in an organ 
in other respects, as far as can be judged, healthy, the author advocates the 
operation of solution (Keratonyxis), on the grounds that it (1) removes a 
deformity which, to many persons, is a serious obstacle to their comfort and 
well-being in life, and that (2) it tends, if the patient occasionally exercise 
the eye by wearing a suitable cataract spectacle, to preserve a healthy condition 
of the retina. Deprive an organ, he said, of its natural stimulus, and its 
nutrition will become either feeble or perverted; in illustration of which, might 
be cited those cases where amblyopia or amaurosis is persistent after the 
removal of a congenital cataract from an adult. 

The primary effect of the removal of a single cataract, as respects vision, is 
in many instances to render it double or confused ; the patient, however, soon 
ceases to regard the impressions conveyed through the retina of the eye which 
has lost its lens, and recovers single and clear vision. In illustration of this, 
the cases recorded by Dr. Andrew Smith in the Edinburgh Medical and Surgical 
Journal, No. 74, are most apposite and conclusive. Three saw objects double 
when the bandage was first removed, and for nearly twenty-four hours, and 
then singly. Two saw double about three hours ; and one of them, two days 
afterwards, upon being surprised, and opening his eyelids suddenly, expe- 
rienced, for a few seconds, the same imperfection. A sixth saw constantly 
double for four days, and after that, as distinctly as ever he' did; and the other 
three cases, as above remarked, always single. 

Mr. Cheshire. — The able paper read by Mr. Solomon had evidently been 
written with great care ; he, however, could not agree with the practice which 
it advocated. Though the author said that double vision subsided, he had 
omittted to state that the vision was forever after the operation confused ; 
indeed, it must be palpable to every one, that the loss of the lens must induce 
confusion of vision. Whereas, if the cataract was not interfered with, the 
fellow eye became as good as two. Clear sight must be better than confused 
vision. 

Mr. L. Parker (the Preisdent) considered the paper they had heard read a 
very valuable one ; he regretted that the author had not illustrated it by a series 



1856.] 



Midwifery. 



265 



of cases from his own practice. The question of the propriety of an operation 
was purely a question of fact ; if one successful case could be adduced, that 
would be an answer to the objection that had been made. 

Mr. Solomon said, in reply, that the objection which had been raised to the 
removal of a single cataract by the operation of solution, on the plea that the 
difference thereby produced in the adjusting power of the two eyes must give 
rise to permanently confused vision, was a theoretical one, and was nullified by 
cases recorded by Dr. Andrew Smith, R. Carmichael, Stevenson, and others, 
also by his own experience in the last seven years at the Birmingham Eye 
Infirmary ; during that period no single instance of permanently confused 
vision, as a result of the operation in question, had come before him. He had 
not kept records of this class of cases, never anticipating that the propriety of 
the operation would have been made, in another place, the subject of a hostile 
attack ; this deficiency in his paper he would, however, supply at the next 
meeting of the Branch, by producing some patients who had lost the lens from 
one eye, and from whom the members of the Society could elicit full particu- 
lars bearing upon the point in discussion. In his experience, he had met with 
several persons in whom the power of adjustment was different in the two eyes, 
and yet the vision was single and clear ; the patients having only discovered 
the defect by accidentally closing the perfect eye. He might observe, in con- 
clusion, that from inquiries he had made, he found that some of the most dis- 
tinguished ophthalmic operators, metropolitan and provincial, in this country, 
and on the Continent, operated on cases of single traumatic cataract by solution. 
— Association Med. Journ., March loth, 1856. 



MIDWIFERY. 

28. Spontaneous Version of the Child. — Dr. Benda relates an interesting case of 
this. A woman was found with an arm-presentation, the waters having escaped. 
The right arm, as far as the half of the humerus, was outside the vagina, little 
swollen. Dr. Benda diagnosed on careful examination the second shoulder- 
presentation. In spite of attempts by himself and his colleague, Dr. Lehfeldt, 
it was impossible to pass the hand into the uterus to seize the foot. While 
waiting for chloroform, the following process, which took place very rapidly, 
was minutely observed. The hitherto relaxed perineum was suddenly dis- 
tended, and the presenting right arm was drawn back into the genital organs ; 
at the same time that the pelvic end of the child rose, the right side of the 
abdomen came first against the perineum, then the pubic end, and during a 
half-revolution upon the long axis the back was directed against the symphysis, 
the left hip was evolved over the perineum, whereupon quickly and in one pain, 
the legs folded upon the abdomen, and the head bent upon the breast followed. 
Thus, out of the second shoulder-presentation, and by strong uterine contrac- 
tions alone, working in a capacious pelvis, the first breech-presentation had 
been developed ; a half-turn upon the transverse axis taking place, as well as 
a half-turn upon the long axis. The child, at first asphyxiated, recovered per- 
fectly. — Brit, and For. Med.-Chirurg. Bev., April, 1856, from Yerhandl. d. Ges. 
fur Geb., 1855. 

29. Complete Inversion of the Uterus, at the Time of Labour, with remarkable 
Absence of the Ordinary Symptoms of that Accident. By F. W. Montgomery, 
M. D., Professor of Midwifery in the King and Queen's College of Physicians. — 
On the 10th of Sept., 1854, Mr. M. called on me to request that I would imme- 
diately visit his wife, whom he stated to be dangerously ill after her confine- 
ment. I accompanied him at once, and on my arrival at the patient's house, 
at 9 o'clock, A. M., found a physician accoucheur, of experience and discretion, 
in attendance, who subsequently gave me the following account of what had 
occurred before my arrival : — 



266 



Progress of the Medical Sciences. 



" He had been sent for to see Mrs. M. about eleven o'clock, P. M., of the 
evening before, when he found her in labour of her fourth child, with the head 
presenting. She was twenty-eight years of age, healthy, and her former labours 
had been quite favourable. The liquor arnnii had been discharged about 
twenty-four hours previously, without pain ; for some time after the doctor's 
seeing her, the pains, which had recently set in, were pretty active, and as the 
pelvis was a roomy one, he expected that the labour would terminate in two or 
three hours. It was not, however, till about half-past seven o'clock that the 
child, a female, was born. During the night, two half drachm doses of ergot 
had been given, with little apparent effect, and it was not till after a pretty 
large dose of laudanum and peppermint was administered that the pains be- 
came really efficient. There was no hemorrhage, but as the placenta did not 
seem likely to come away speedily, the womb being sluggish, and not disposed 
to contract, the nurse- tender was directed to make pressure over the uterus, 
while the doctor drew down the cord. In about ten or fifteen minutes, the 
placenta came away, followed, on the instant, by a large round tumour, which 
passed completely out of the vagina, and was, for an instant, supposed to be the 
head of a second child, which it equalled in size. 

"It was, however, soon ascertained to be the uterus completely inverted, no 
os being to be felt. The tumour was at once returned within the vagina with- 
out much difficulty, but pressure on the fundus failed to effect its restoration 
to its proper place. There was some hemorrhage, both on the sudden descent 
of the uterus and after its return, but not much. The patient felt a pressing 
desire to make water, and a distressing sense of pressure on the bladder, and 
becoming anxious, it was deemed advisable to have further advice. Although 
alarmed, from the knowledge that there was something wrong, she presented 
little change in countenance or pulse, no faintness, and but little hemorrhage. 
Her recovery, after the replacement of the uterus, went on most favourably, 
and at the end of a month she was as well as after any previous confinement." 
" Feb., 1856 : she has been in good health ever since, and now considers herself 
two or three months pregnant." 

Such are the accounts I received of this case at the time of the accident and 
since, and I am now to state what I was myself present at. I was at the 
patient's bedside at nine o'clock, delivery having taken place at half-past seven 
o'clock. I found her looking tranquil, her pulse good, firm, and quiet, and 
although she was anxious about herself, believing that there was some cause 
of alarm, there was not the least approach to that kind of overwhelming nerv- 
ous distress which so often accompanies so serious an accident. She com- 
plained of nothing except the sense of pressure on the bladder ; there were 
very smart periodical pains, which, however, she rather made light of, as she 
regarded them only as after-pains, such as she had had after former labours, 
which, indeed, they perfectly resembled ; there was very little hemorrhage. 

On examining the abdomen, there was to be felt a considerable tumour in the 
supra-pubic region, and taking this fact with the other conditions above men- 
tioned, I confess I felt almost certain that it could not be a case of inversion, 
the symptoms were so widely different from those which almost universal ex- 
perience would lead us to expect. An examination per vaginam, however, soon 
removed all doubt. I found that passage, indeed I may say the whole pelvic 
cavity, filled up with a firm fleshy tumour, ichich was perfectly insensible; and 
on passing the finger along it upwards, it was found to terminate in a cut de sac 
all around, and about an inch within the margin of the os uteri ; so that the 
inversion, or perhaps, more properly, the eversion of the organ was as com- 
plete as I believe it ever is in the first instance. 1 

In proceeding to effect the reduction, I, in the first place, put the patient fully 
under the influence of chloroform ; I then introduced my hand, and grasping 
the tumour, I compressed it as strongly as I could from the lateral circumfer- 
ence towards the centre, and at the same time pushed it upwards and forwards 

1 When the displacement has been for some weeks or months in existence, the tissue 
of the organ having gradually contracted and greatly diminished in bulk, the cul de-sac 
vanishes. 



1856.] 



Midwifery. 



267 



towards the umbilicus ; for several minutes, this proceeding seemed quite with- 
out effect; but at length, I felt the tumour begin to yield, receding and gliding, 
as it were, by a spontaneous movement of the whole tumour upwards, and not 
of the lowest part of the fundus re-entering itself; and then, all at once, it 
suddenly almost sprung away from my hand, and was restored to its proper 
place. I pressed my hand into its cavity, up to the fundus, and kept it there 
for a few minutes, and before withdrawing it, I took the precaution of making 
sure that there was no dimpling in, or cupping of the fundus, by feeling the 
hand so retained with my other hand through the parietes of the abdomen. 
The resistance to the replacement of the inverted organ was so great, that I do 
not think I should ever have succeeded had I not put the patient to sleep, and 
subdued its contractile efforts by the administration of chloroform. I cannot 
but consider myself very fortunate, indeed, in having succeeded in restoring 
this uterus fully an hour and a half after its complete inversion, during which 
interval, moreover, active contractions had not ceased to occur. Dr. Merriman 
says that under such circumstances, unless the inversion be reduced in a few 
minutes after the accident has happened, all attempts to return it will be inef- 
fectual. And Denman tells us that although present at the moment when the 
accident occurred in a patient of his own, and only waiting until he had sepa- 
rated the placenta, he could not possibly effect the replacement of the organ. 

Inversion of the uterus at the time of delivery is, like the spontaneous evolu- 
tion of the child, an accident of such rare occurrence, especially in private 
practice, that few, even of those most extensively engaged in practice, have 
ever seen a case of it ; and still fewer have been actually present at the moment 
it took place. I have spoken with several practitioners on this subject, and, 
like myself until lately, none of them had ever met with it in private practice ; 
one gentleman said that, in forty years, he had been called in once to a case of 
the kind, but found the lady dead when he arrived ; another gentleman had 
seen it once in thirty years. The late Dr. Douglass told me, within a year or 
two before his death, that he had, just then, met with it for the first time, in 
private ; and he assured me that it had taken place after he had left the lady 
apparently safe and well. Denman says expressly (Introduction, p. 5G6, 5th 
edit.), that it was an accident of very rare occurrence during the whole of his 
life ; and Dr. Ramsbotham, whose practice and experience were equally ex- 
tended, says he never saw a case immediately after inversion. 

The production of this accident is, I think, too generally ascribed to injudi- 
cious traction of the cord to bring down the placenta ; and the inevitable con- 
sequence of this presumption is, that whenever it is found to have occurred, it 
is taken for granted, that the attendant practitioner must be to blame as hav- 
ing thus caused it, when, in truth, all that depended on him may have been 
done with all proper care and skill, and the accident have arisen from causes 
over which he had no control ; at the same time, undue pressure over the 
fundus uteri, and strong traction by the cord, are likely to be productive of so 
many untoward, or even fatal consequences, that no prohibition of their adop- 
tion can be too strongly enforced ; and, I may add, that the last two cases of 
inversion, of which I am aware, as having happened in this city, were, I be- 
lieve, justly attributed to the combined action of these agencies; but, if this 
displacement were easily produced by the mismanagement alluded to, instead 
of being, as it confessedly is, very rare, it would assuredly be of very frequent 
occurrence indeed, considering that the objectionable plan of interference is so 
constantly that of midwives, and too often of better educated practitioners. 

I think we have quite sufficient grounds for believing, with Merriman, 1 that 
"there can be no doubt that a spontaneous inversion has sometimes occurred 
or, to use the words of Dr. Blundell, 2 that " the whole uterus may be pushed 
down, and this independently of anything done by the obstetrician." Ruysch 
states that the accident may happen, and did so in his own practice, when no 
undue force was used ; and after animadverting on the impropriety of forcible 
extraction of the placenta as the general cause of this accident, he adds, " ali- 
quando tamen, ortum ducit a conatibus post partum remanentibus." 



1 Synopsis, &c, p. 1857. 



2 Principles and Practice of Obstetricy, p. 688. 



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Kokitansky 1 describes a condition of the uterus immediately after delivery, 
which might readily lead to inversion : it consists in a paralysis of the placen- 
tal portion of the uterus, occurring at the same time that the surrounding parts 
go through the ordinary processes of reduction ; the part alluded to is thus, he 
says, " forced into the cavity of the uterus by the contraction of the surround- 
ing tissue, so as to project in the shape of a conical tumour, and a slight in- 
dentation is noticed at the corresponding point of the external surface. And 
he adds an observation, the truth of which I had occasion to verify, I may say 
anticipate, several years ago. "The close resemblance of the paralyzed seg- 
ment of the uterus to a fibrous polypus may easily induce a mistake in the 
diagnosis, and nothing but a minute examination of the tissue can solve the 
question. The affection always causes hemorrhage, which lasts for several 
weeks after childbirth, and proves fatal by the consequent exhaustion/' 

The following case was an instance of this occurrence. In July, 1831, I 
was summoned, at four o'clock in the morning, to see a lady who had been de- 
livered at 10 o'clock the previous night. The placenta was still retained, 
although she had had, all through the night, rather severe expulsive pains ; she 
had lost a good deal of blood. On examination, I found the serous surface of 
the placenta lying upon, and pressed against, the internal surface of the os 
uteri ; but, although the uterine contraction continued, I could not get it down 
by traction of the cord. On passing my hand into the uterus, I found the pla- 
centa was adhering to a globular tumour, which seemed to be as large as a 
good sized orange, and which, at the moment, I had no doubt was a fibrous 
tumour projecting from the inner surface of the uterus. To this tumour the 
placenta was morbidly adherent, and was only separated therefrom with diffi- 
culty. Having, however, accomplished this, and turned my hand freely in the 
uterus, to secure its complete contraction, the tumour, which was evidently the 
"placental portion" of the uterus partially inverted, completely disappeared, 
and the lady afterwards recovered well. Denman relates a case very much 
resembling this. 2 

With regard to those cases, in which inversion has been supposed to have 
occurred spontaneously, after the departure of the medical attendant, I think we 
may take for granted that in not a few of them the displacement had commenced 
while he was present, though without his knowledge ; perhaps with very slight 
manifestations of its occurrence ; or it may have remained unnoticed from want 
of sufficient observation and proper examination on his part. In the Gazette 
des Hopitaux, for 7th Feb. last, there is a case reported in which partial inver- 
sion of the uterus was only discovered on the 6th December, in a patient who 
is stated to have been safely delivered on the 13th November ; but from the 
whole details of the case, it appears almost evident that the inversion occurred 
at the time of labour, but was not then noticed. 

There is obviously this danger in supposing, as so many do, that this acci- 
dent is always attended and announced by a particular train of urgent symp- 
toms ; that if such symptoms are not observed, the attendant may be induced 
to conclude, what he would naturally so much desire, that no such accident 
could have happened, and so the patient is left to die, or linger out a life of 
misery. The instances in which this has happened are numerous indeed ; one 
such is above referred to, and another we may quote from Dr. Merriman, 3 in 
which it is stated that "the placenta came away without any difficulty, and 
certainly without any suspicion of injury to the uterus but, between six and 
seven months afterwards, it was discovered that the uterus was inverted. 

Now, when we succeed in effecting the replacement of a completely inverted 
uterus, how is its restoration really accomplished ? Is it, as is generally stated 
in books, by re-inverting first the dependent fundus, or, in the words of Sir C. 
M. Clarke, " by making pressure on the lower part only of the tumour, so as 
to cause this part to be received into that above it/' 4 and so on, gradually up 
to the angle where the cervix is flexed on itself? Judging from what happened 
in this case of Mrs. M., and from the accounts given by others of what hap- 



1 Pathological Anatomy, vol. ii. p. 304. 
3 Synopsis, p. 299. 



2 Op. jam. cit. p. 564. 

4 Diseases of Females, Part i. p. 151. 



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Midwifery. 



269 



pened in their cases, I think the above is not the mode of reduction ; but that, 
as we compress the bulk of the tumour, and try to press the fundus back into 
itself, and push it upwards, the flexure at the cervix yields, and presently the 
fundus seems to escape upwards by springing as it were from our hand; so 
that the part which was last inverted is the first restored. This springing away 
from the hand is expressly mentioned by more than one writer of authority, 1 
and is, I presume, produced by the contraction of the orbicular fibres of the 
partially restored cervix lifting up quickly the globe of the fundus. 

I have now only to observe that, however small is the number of cases of in- 
verted uterus met with in practice, it would be still smaller, if it were the uni- 
versal rule carefully to examine every recently delivered woman, both through 
the abdominal parietes, to ascertain the size and form of the uterus, and also 
per vaginam, to be satisfied that there was no tumour protruding into that 
canal ; nothing can excuse the neglect of this simple proceeding, and if it were 
invariably adopted, I think, with Mr. Xewnham, 2 that " chronic inversion of 
the uterus would be known only by description.'' — Dublin Hospital Gazette, 
April 1, 1856. 

30. Placenta Prcevia. — In our previous number (p. 523, et seq.), we gave 
some interesting cases of placenta praevia, by Dr. Thos. Radford, and now 
jontinue them : — 

Case X. — Jan. 2, 1823, Mrs. Fildes, midwife, sent for me to visit a hospital 
patient residing in Cock Gates, in labour and flooding. She was at the end of 
pregnancy, and in going up stairs had fallen, and immediately felt sick and 
faintish. In about an hour afterwards, she had a discharge of blood, followed, 
by pains, which continued to increase in frequency and strength. The hemor- 
rhage was now great; her countenance was very pale; her pulse was frequent 
and feeble. On an examination per vaginam, I found the os uteri opened to 
about the size of a shilling ; but it was firm. On passing the finger through it, 
I detected the placenta. I plugged the vagina, and had the abdominal bandage 
put on, with the uterine compress placed under it, and then tightened, so as 
to effectually support the womb ; the retaining bandage was also applied. She 
was carefully watched for some time; and as there was no external bleeding, 
;>r indication of any internal loss, I left her in the care of her midwife, strictly 
directing her to send again for me if there were any grounds for alarm. 

In about four hours I called, and found the pains recurring more frequently 
and stronger. There had been no bleeding, and she seemed much better. I 
now withdrew the plug, and ascertained that the os uteri was considerably 
dilated, and softer, and the loosened placenta lying within it. There was some 
bleeding during the pains. After having placed on the regulating bandage, I 
passed the hand, and further detached the placenta to such an extent as I 
thought would allow the head of the child to pass, and then ruptured the mem- 
branes, directing the midwife at the same time to tighten the bandage. The 
water freely escaped ; and in a short time the head of the child began to press 
on the os uteri, which soon yielded. The loosened portion of the placenta fell 
to one side, and the child passed by it, and in about three hours it was born 
alive. The placenta followed in about half an hour. There was no further 
hemorrhage, and her recovery was uninterrupted. A drachm of laudanum 
was given. 

Remarks. — This case is another example of the value of the plug. A very 
short time elapsed between the accident and the occurrence of labour pain. 
The location of the placenta on the cervix and os uteri tended to produce these 
effects sooner than if this organ had been situated elsewhere. The irritation 
which the os sustained by the mechanical separation of the placenta was soon 
felt by the fundus and body of the uterus. The hemorrhage was brought on 
by the fall ; but sooner or later flooding would doubtless have occurred, if no 
such accident had happened. 

Case XI. — May 5, 1827, I visited a hospital patient residing in Cook Street, 
Salford, under Mrs. Booth's care, who was stated to be in labour, and in danger 



1 Merriman, Synopsis, p. 229. 

No. LXIIL— July 1856. 18 



Essay, p. 8. 



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[July 



from flooding. She was in the last month of her seventh pregnancy. The 
pains were frequent and sharp ; she felt faintish ; looked pale ; and her pulse 
was feeble. The discharge of blood had continued for three hours, and was 
now excessive, and increased on the accession of each pain. She had a slight 
attack a month before, which was soon suppressed by rest, cool air, and cold 
external applications. The os uteri was now dilated to the size of a shilling, 
but extremely rigid ; it had the feel of a cartilaginous ring. I passed my finger 
through it, and I thought I perceived the placenta. Under these circumstances, 
I determined to effectually plug the vagina, to place on the abdominal bandage, 
and under it the uterine compress, and to fix the retaining bandage. She was 
carefully watched for some time, and feeling assured she was safe, I left her, 
having directed the midwife to send for me if any unfavourable symptom 
occurred. 

In about six hours I was sent for, as the pains were now very frequent and 
strong. She was much improved in appearance, and her pulse was firmer. 
There had not been the slightest bleeding. On withdrawing the sponge, some 
small coagula followed, and immediately afterwards there was a fresh flow of 
blood. The os uteri was now opened fully to the size of a crown-piece, and felt 
considerably softer, and, as I thought, dilatable. A portion of the placenta 
with the membranes were found, in the absence of the pain, within it ; and 
above I could feel the head of the child. As the uterus was now acting well, 
after having had placed on the regulating bandage, I passed my hand onward 
to the side where the membranes offered, and having first freely detached a 
sufficient extent of the placenta to allow the head to pass, I then ruptured them. 
The bandage was kept so tight as constantly to compress the uterus, as it 
changed in size by the escape of the waters. The pains were very strong ; 
and the head of the child soon engaged within the os uteri, pushing the pla- 
centa aside as it descended into the pelvis. The child was born alive. The 
placenta was found lying loose in the vagina, and withdrawn. A drachm of 
tinctura opii was administered ; and the circular bandage and uterine com- 
press were applied. 

Remarks.— No other means would have answered in this case so well as the 
plug ; blood was saved and time obtained for the os uteri to soften and dilate ; 
in fact, no other plan could have been safely adopted. If the membranes had 
been ruptured (which might assuredly have been done by means of a stilette), 
the hazards of protraction would have been very great with the os uteri so 
hard ; and the child to a certainty would have been destroyed by the contusion 
and the laceration which the placenta must sustain from the pressure of its 
head on so unyielding a tissue. To prevent such an injurious effect on the 
placental structure, is one object in my practice of detaching a considerable 
portion of it from the uterus before rupturing the membranes is adopted. 

Case XII.— On October 25, 1832, at 11 o'clock P. M., I was desired to see a 
hospital patient residing in Oldfield Lane, Salford, by Mrs. Bloineley. She 
was at the latter part of the sixth month of her fifth pregnancy. She had suf- 
fered from slight hemorrhages at different times for several weeks. During 
the afternoon and evening (of this day, 25th Oct.), she had copious discharges 
of blood, which recurred with each pain. When I arrived, she was very much 
exhausted; the pulse was feeble and indistinct; her lips were pale, and her 
face was deadly white ; her forehead was bedewed with cold sweat ; and her 
hands and arms (uncovered) were very cold; her feet felt 'warmer; her voice 
was very weak. Upon gently turning her on her side, to examine her, she 
fainted, and remained in an apparently lifeless state for some time, from which 
she slowly recovered, and was very much exhausted. The vagina was found 
full of coagulated blood ; the os uteri was high in the pelvis, and was felt (with 
considerable difficulty) to be firm and undilated. Although I suspected that 
the placenta was placed here, I was quite unable to verify my suspicion. The 
hemorrhage continued, but it was rather less violent. 

Her exhausted state demanded that some plan should be adopted, which 
would immediately suppress the bleeding. The undeveloped cervix, and the 
hard undilated os uteri, were unfavourable for any but that of effectually plug- 
ging the vagina. After the abdominal bandage was put on, and the uterine 



1856.] 



Midwifery. 



271 



compress placed under it, the vagina was completely filled with pieces of 
sponge : the first piece I carried up forcibly against the os uteri ; the retaining 
bandage was afterwards fixed. She was ordered absolute quietude ; and as 
the surface of her body felt cold, she was warmly covered. Some brandy was 
administered with gruel, and repeated from time to time. 

Although the vital power was so depressed, the pains increased in frequency 
and power, and in the course of five hours the plug was pushed further out- 
wards ; and on removing the bandage placed to retain it, the sponges were for- 
cibly expelled. On examination, I found the placenta advanced to the os exter- 
num ; and this organ, in connection with the entire ovum, was immediately 
forced away. The discharge ceased from the moment the plug was passed, 
and never returned ; only a little coagulated blood came along with the ovum. 
The bandage was tightened over the compress. A drachm of tinctura opii 
was given. 

On examining the placenta, a portion of its edge appeared to have been first 
separated ; its surface was dark-coloured, and its tissue was loaded with coagu- 
lated blood. This poor woman was well nursed, and after some time she 
recovered, having been kept perfectly quiet, well supported, and her bowels 
regulated. 

Remarks. — The value of the plug is eminently conspicuous in this case ; it 
effectually arrested the bleeding at a time when perhaps the loss of very little 
more blood would have been fatal. The existence of uterine pain led me to 
conclude that some dilatation was going on at the upper portion of the cervix, 
and therefore I pushed the first piece of sponge more forcibly against the os 
uteri than I should have done whilst it was so high, under other circumstances. 

The fallacy of the dogma of some authors is well exemplified in this case, 
viz : that when hemorrhage is so great as to require delivery, this operation 
may be safely performed. 

Case XIII. — March 25, 1819, at the suggestion of Mr. Spence, I was called 
to Mrs. A., who was in the sixth month of her third pregnancy. She had been 
well up to this time; but she now had a profuse flooding, which had come on 
without any obvious cause. Cold vinegar and water had been externally ap- 
plied, and cool air freely admitted into her apartment. She had taken a mix- 
ture with acidum sulphuricum dilutum and tinctura opii, and afterwards 
plumbi acetas and opium, in suitable doses, all without abating the discharge. 
She was pale ; her skin felt coldish ; her pulse was frequent and small ; and 
she felt faintish. I found some coagula in the vagina, and fresh blood still 
flowed. The os uteri was high up in the pelvis, and was closed ; the cervix 
was undeveloped. I could not prudently make further inquiries, and there- 
fore I was ignorant as to the precise location of the placenta. I suspected it 
was fixed on the cervix. There was no pain. The circular abdominal band- 
age aud the uterine compress, placed under it, was firmly applied. The vagina 
was well plugged with sponges, but I carefully avoided passing the first piece 
too high, so as to forcibly press against the os uteri. The retaining bandage 
was fixed. Stimulants and supports were cautiously administered. The ex- 
ternal bleeding ceased ; and we were convinced there was no internal loss. 
The plug was allowed to remain for about eight hours. At the expiration of 
this time, although there was no discharge, yet as she complained of irritation, 
it was removed. As nothing further occurred, I left the patient under the 
care of her medical attendant, who afterwards informed me that nothing unfa- 
vourable happened until she reached the eighth month, when she had a very 
slight discharge of blood, which was soon arrested by cold applications, etc. 

She went on to the end of her pregnancy, and her labour was natural. The 
child was born alive. Mr. S. informed me that the membranes had ruptured 
before his arrival, and that he felt a small portion of the placenta hanging 
through the os uteri. 

Remarks. — We have here a good example of the advantage of not meddling, 
beyond adopting suitable measures to stop the hemorrhage. 

Case XIV. — May 25, 1824, Mrs. Such sent for me to see a hospital patient 
residing in Tib Street, who had been in labour for several hours, and was flood- 
ing. This was her tenth pregnancy. She was large in size, and the uterus 



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seemed to project more forwards than usual. The pains were frequent, but 
they were very weak. "When the midwife first visited her, the hemorrhage 
was very trifling, but afterwards it rather increased, but still not to any great 
degree ; and therefore she did not send sooner for further assistance. Cold 
vinegar and water had been externally applied ; the apartment had been kept 
cool ; and the patient constantly kept in bed. Although the discharge had 
continued for some time, the woman did not appear to have suffered from the 
loss. I found the os uteri situated rather backwards; it was very soft, and 
dilated to more than the size of a crown-piece ; along with the flaccid mem- 
branes I felt a small slip of placenta, and higher up I perceived the head of the 
child. On the accession of pain the membranes were only just made tense. 

I had the patient placed on the back, and a regulating bandage applied and 
tightened. I now gave her half a drachm of secale cornutum, powdered and 
infused, and repeated the dose in half an hour ; after which, the pains increased 
in power. 

Having directed the midwife to tightly draw the bandage, I passed my hand, 
and, as far as necessary, I detached a portion of the placenta, and then rup- 
tured the membranes. A very large quantity of liquor amnii soon escaped ; 
and the head of the child rapidly descended (finding no obstacle from the os 
uteri) into the pelvis, and was born alive in about two hours. There was not 
the slightest bleeding after the completion of the operation. The placenta was 
immediately expelled. The uterus was well contracted. The bandage was 
now readjusted and pinned, with a large compress under it. 

Remarks. — Why the hemorrhage was not very great, may be accounted for, 
partly from the comparatively small portion of the placenta which had been 
fixed to the os uteri, and partly from the very gradual separation of this organ 
from the uterus, in consequence of the weak pains, which necessarily effected 
the dilatation of the os very slowly. The atony of the uterus most likely arose 
from the large quantity of liquor amnii, and also from frequent pregnancy. It 
was thought prudent (there being no depression" of the vital power) to adminis- 
ter the secale cornutum before the manual operation was performed, to guard 
against the risk of further bleeding. Obliquity of the uterus, to a considerable 
degree, existed, on which account I had the patient placed, to labour, on the 
back. The aid derived from the regulating bandage was very great; and 
when it was drawn tight, the fundus and body of the uterus were raised from 
the anterior dependent position, and retained in the line of the axis of the inlet 
of the pelvis. 

Case XV. — March 11, 1824. Early in the morning, Mr. Dadley desired me 
to visit a hospital patient living in Miller's Lane, to whom he had been called 
by Mrs. Frost. She was in labour of her seventh child. Mr. Dadley found her 
very much reduced from hemorrhage, which had continued for some time pre- 
viously to his being sent for, and which now recurred with greater violence 
during the pains, which were frequent and short. The os uteri was low down 
in the pelvis, soft, and dilated to about the size of a half-crown. He discovered 
a portion of the placenta with the membranes, and higher up, the head of the 
child. At this time a messenger was dispatched for me ; but before I arrived, 
she was dead. Mr. Dadley stated the symptoms of exhaustion became so 
urgent, that he felt he should not be justified in waiting for me, and therefore 
he determined on immediate delivery. He passed his hand by the side of the 
placenta, and then ruptured the membranes : the patient immediately fainted 
and died. 

Permission was obtained for a post-mortem examination. The aspect of the 
body was white and exsanguined. The abdominal viscera were pale. The 
uterus was flaccid and large in size ; on cutting through its parietes, they were 
found thinner than usual. The placenta was also thin, and extensively con- 
nected to the right side of the cervix and body of the womb. The os uteri was 
nearly fully opened, and within it there was a narrow loosened portion of pla- 
centa. 

Remarks. — Although I did not see the patient during her life, there can be 
no doubt the vital powers were very greatly exhausted from the hemorrhage, 
which had been incessant for a very considerable length of time. 



1856.] 



Midwifery. 



273; 



The case is an example of an opposite character to some of those which are 
already cited. The atonic state of the uterus, evinced by the very feeble pains, 
and further proved by the post-mortem examination, no doubt mainly contri- 
buted to the fatal issue. If the fundus and body had acted energetically at an 
early period of the labour, the os uteri being so soft and unresistant, it is 
most probable the woman would have been saved under judicious obstetric 
management. 

Case XVI. — April 25, 1825. Through the kindness of my colleague Mr. Faw- 
dington, I was present at the post-mortem examination of a hospital patient. I 
was^told she had lost a very large quantity of blood, which did not escape by 
large impetuous gushes, which sometimes immediately destroy a woman, but 
by an incessant dribbling discharge. As her dissolution seemed impending, 
it was deemed right to deliver her, although the os uteri was high, felt rigid, 
and was very little dilated. Mr. Fawdington stated that he performed the 
operation very slowly and carefully, but with great difficulty. The child was 
stillborn. She died on the second day after her delivery. 

On inspecting the body, it was white and exsanguine. There was a little 
watery fluid in the peritoneal cavity. The uterus was soft and larger than 
usual. The os was ragged, there being several lacerations through its tissue, 
which appeared as if it was gangrenous. 

Case XYII. — March 11, 1830. Early in the morning, Mrs.— — , midwife, 
sent for me to see a patient, whom the messenger stated to be in labour, and in 
great danger. She was in the eighth month of her sixth pregnancy. She had 
flooded, more or less constantly, for a fortnight. Her labour began the even- 
ing before, and she had strong pains during the whole of the night, which were 
accompanied by an increased discharge of blood. She was very much ex- 
hausted. Her countenance was extremely pale. The surface of the body felt 
very cold. Her pulse was scarcely perceptible. There was great restlessness, 
and she gasped for breath. The os uteri was soft, and dilated to about the 
size of a dollar. A portion of the placenta protruded through it into the va- 
gina. As her death was inevitable, I deemed it right only to tighten the 
bandage, which was already about her, and to pass a piece of sponge per 
vaginam, more for the sake of satisfaction to her friends than to serve any 
other purpose. Brandy and water, etc., were ordered, but she had difficulty 
in swallowing. She died in about an hour. 

Consent was obtained to examine the body the day following. It was white, 
as if altogether drained of blood. There was extreme paleness observable in 
the abdominal viscera. On cutting into the uterus, and opening the mem- 
branes, some liquor amnii escaped. The child lay in a natural position, and 
its body was very white, as if it had also lost its blood. The placenta was re- 
markably thin, and extensively connected ; it covered the os, the cervix, and 
the body of the womb; it was more like a placental bag than like (as it is 
usually called) " a cake." That portion of this organ into which the funis was 
inserted was placed nearly over the centre of the os uteri. This opening was 
soft and considerably dilated, and was filled with the placenta, which was lace- 
rated, and its tissue loaded with coagulated blood. 

Eemarks. — The midwife was most unpardonable in allowing this poor crea- 
ture to bleed to death without earlier sending for further assistance. What 
individual efforts she might have ignorantly made to save the woman, I 
am unable to state; although I strongly suspect she (the midwife) had rudely 
meddled with the placenta. The extensive connection of this organ tended, 
no doubt, to increase the hazards which usually belong to a central position of 
it over the os uteri. An early and judicious delivery would have afforded her 
the best, and indeed the only, chance of being saved. The whiteness of the 
child's body showed that its blood had drained away ; and there is no doubt 
that the source from whence it escaped was the lacerated placental tissue. 
(Vide Lancet, loc. cit.) 

Case XVIII. — June 23, 1847. I received a note from Mr. Dunn, requesting 
me to see Mrs. L., who was flooding, in consultation with him, and to bring 
my galvanic apparatus along with me. He stated to me that she was now in 
labour of her fifth child, and had previously two attacks of slight hemorrhage, 



274 



Progress of the Medical Sciences. 



[July 



both of which had been arrested by quietude, cold applications, and an acid 
mixture. She was a delicate leucophlegmatic 'woman, about 40 years of age. 

When Mr. Dunn first saw her, she had felt trifling pains; and the discharge, 
which at first was only moderate, gradually increased. There was no obvious 
cause to account either for this or the two former attacks. The os uteri was thin 
and partially dilated. The membranes and a portion of the placenta were felt, 
and a little above, the head of the child presented. An abdominal bandage had 
been applied, and cold water and vinegar externally used. As the pains con- 
tinued to come on very frequently, and were very weak, and the hemorrhage 
w r as much greater, I was now sent for. I found this lady very feeble, evidently 
suffering the effects of loss of blood. Her countenance was pallid, especially 
the lips. The skin was pale ; the pulse frequent and small ; the os uteri was 
soft and thin, and dilated as nearly as possible to the size of a crown-piece. 
The pains seemed very weak and ineffective, and indeed the membranes were 
very slightly affected during their continuance ; a considerable sized portion 
of placenta was felt in connection with them. 

On applying my hand on the abdomen during the contraction of the uterus, 
I ascertained that this organ did not then become hard and resistant, but it 
continued softish. Under these circumstances, we continued first to pass the 
galvanic currents through the longitudinal and transverse axis of the uterus ; 
and afterwards to adopt such measures as we thought best suitable for the case. 
After a very short time the uterus acted more energetically. The regulating 
bandage was now put on, and afterwards the hand was introduced, and a por- 
tion of the placenta was detached, and the membranes were ruptured. The 
waters being discharged, the head very soon came down, and pressed on the 
os uteri. The hemorrhage had now entirely ceased. Although the pains were 
much stronger, we considered it prudent to again pass the galvanic current 
through the uterus ; and we continued to do so at intervals for about an hour. 
During this time the pains strengthened ; and the head of the child descended 
and passed by the placenta, pressing this organ against the side of the pelvis. 
The child was born (alive) in about three hours after we first applied galvanism. 
The placenta was removed from the vagina in half an hour, and there was only 
an ordinary discharge of blood. 

Remarks. — An atonic state of the uterus in cases of unavoidable hemorrhage 
is always to be deplored, for although the placenta is always more or less sepa- 
rated by each pain, yet active contraction of the fundus and body of the uterus, 
especially when there coexists a dilated and a dilatable os, is most advantageous, 
and tends, under proper obstetric management, to save the woman. The os 
was in this favourable condition, and by the application of galvanism, active 
and effective, uterine contraction -was induced. The salutary effects of this 
powerful agent are not confined alone to giving energy to the uterus ; but the 
depressed vital powers are raised by its use. 

Case XIX. — April 13, 1848. I saw a poor woman residing in Canal Street, 
along with my respected friend and late pupil, Mr. Dorrington. She was in 
labour of her seventh child. He said he found her flooding excessively ; the 
os uteri very little dilated and firm. The midwife informed him the patient 
had flooded very slightly twice before. Each of these attacks had come on 
without any assignable cause. The pains were regular, but very short and 
weak. Mr. Dorrington had a bandage, with a compress under it, tightly ap- 
plied. He ordered her a drachm of laudanum. He remained with the patient 
for some time ; and then, as there was no hemorrhage, he left, and in about 
three to four hours he called again to see her; and as there was no further dis- 
charge of blood, and as there was an improvement in her pulse, and the pains 
still were frequent and feeble, he determined to withdraw the plug. Some 
small coagula with the liquor amnii immediately came away, and soon after- 
wards fresh blood flowed. Mr. Dorrington found the os uteri considerably 
dilated, and very soft, and he now felt a portion of the placenta, and through 
the open membranes he touched the head of the child. At this time I was sent 
for, and requested to bring my galvanic apparatus. She appeared to have lost 
a large quantity of blood; she was very pale; her pulse was frequent and 
small ; and she was faintish. I passed the hand and found the os uteri dilated 



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to a considerable size and dilatable, and a portion of placenta loosely hanging 
through it. With Mr. Dorrington's concurrence, I further detached this organ 
before withdrawing my hand. 

The galvanic apparatus having during this time been got in readiness, the 
conductors were successively applied on the abdomen, so that the current 
would pass transversely and longitudinally through the uterus. One conductor 
was also placed on the spine, and the other on the lower portion of the body 
of the womb, with the view of transmitting the galvanic current along the 
course of the nerves. "We were well satisfied with the effects of each trial. 
Uterine action soon improved, and in half an hour was very effective. The 
head of the child was pushed through the os uteri, forcing the placenta aside. 
The hemorrhage had now ceased, and as the pains returned spontaneously, the 
labour was left to be finished by nature. The child was born alive in about 
three hours from our first essay with galvanism. The placenta was soon ex- 
pelled. There was more discharge than usual. The patient recovered well. 

Remarks. — The plug proved of great utility, as there is not much doubt the 
hemorrhage would have been much greater than it was, and not unlikely would 
have been fatal, if this mode of treatment had not in the first instance been 
adopted. The spontaneous rupture of the membranes did not arrest or even 
abate the discharge. The continuance of the bleeding was in some degree 
owing to the atonic state of the uterus, and in some degree to leaving the pla- 
centa to have its connections gradually broken. This organ was placed in a 
position favourable for the escape of blood, in consequence of the want of active 
uterine contraction, which would have quickly separated a necessary portion 
of the placenta by the head passing rapidly through the os uteri. These two 
important desiderata were obtained by artificially detaching a portion of the 
placenta, and the induction of brisk uterine contraction by the aid of gal- 
vanism. 

Case XX. — Jan. 7, 1831. I was requested by Mr. to visit Mrs. L., 

from whom I received the following statement of the case up to the time I was 
called in. She was in the sixth month of her twelfth pregnancy, when she 
began to flood rather copiously whilst quietly sitting on a chair. She had 
several slight attacks at intervals of seven to ten days. Rest in the recumbent 
position, cool air, cold applications, and an acid mixture, with laudanum, were 
ordered. Notwithstanding she suffered from these repeated discharges of blood, 
she arrived at the end of the eighth month. On the evening of the above date, 
she had again a slight flow; but she had not been in bed above an hour before 
the bleeding became very profuse. She rose from bed, and stood leaning for- 
wards over the edge of it, until she fainted, when she fortunately fell (forwards) 
on the bed. 

Mr. was now sent for ; he found her somewhat recovered, although she 

still remained rather faint. Her pulse was very weak ; her countenance was 
very pallid; the surface of her body felt coldish. The os uteri, he said, was 
placed rather low, and dilated to about the size of a shilling, but it was very 
firm. The hemorrhage had been very great, for the body and bed linen were 
completely saturated, and there was a large pool of blood on the floor ; and 
therefore, although the organic state was unfavourable, as he considered it 
hazardous to risk another attack, he proposed immediate delivery ; but she de- 
terminately refused to allow it. 

At this time I was sent for. The discharge continued to slightly dribble. 
The os uteri was not more dilated than before mentioned, and was firm and 
undilatable. The placenta I distinctly felt. Under these circumstances, I did 
not feel warranted to acquiesce in the necessity and propriety of delivery ; but 
I proposed to plug the vagina, and to apply an abdominal bandage, and a com- 
press under it, over the uterus. A drachm of tincture of opium was adminis- 
tered. The discharge was now completely arrested. Brandy and water and 
suitable support were given. She was well watched for eight hours, during 
which time she improved, and had regular pains. The plug was now with- 
drawn, and along with it some coagula came away, which was immediately 
followed by fresh blood. The os uteri was now considerably more dilated and 
dilatable ; and as she consented to submit to delivery, I passed my hand (having 



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had placed on a regulating bandage), and first separated a large portion of the 
placenta (which was centrally placed over the os), and then ruptured the mem- 
branes. I readily seized a foot, by which I brought the child's hips to bear on the 
os uteri, when I rested, and afterwards, as there was now no bleeding, I slowly 
extracted the body and head, co-operating in my efforts with the pains. The 
child was dead, and extremely white, as if it had also been drained of its blood. 
The placenta, being loose in the vagina, was immediately removed ; its organi- 
zation was a good deal broken up. There was only an ordinary discharge. A 
drachm of tincture of opium was administered. She continued to go on favour- 
ably for the first three clays, at the end of which time she had a shivering, suc- 
ceeded by a febrile heat. She felt pain in the hypogastric region, which was 
tender on pressure; and her right lower limb felt stiff, and began to swell; it 
was very pale ; terminating in a slight attack of "phlegmasia dolens. ;; Saline 
and suitable aperient medicines were prescribed. Leeches, poultices, and 
frictions, were applied. She gradually recovered. 

Remarks. — The blood which had run on the floor was, as far as possible, 
taken up, and the quantity was very great. Her loss in the aggregate must 
have been very considerable. She bore a larger loss than most pregnant women 
could have endured without nearly completely exhausting their vital powers. 
It is, however, a fact, that every woman in this condition bears loss of blood 
much better than at other times. It was perhaps a fortunate, although not a 
very courteous determination, that she refused the proposition of her medical 
attendant, for then the os uteri was not in a fit state for delivery to be safely 
performed ; and it is not unlikely if this operation had been forcibly under- 
taken, her life might have been sacrificed. The plug answered well to secure 
her until the os uteri became sufficiently soft and open. The child doubtless 
died from hemorrhage. It was very white, and had a very different aspect 
from that which is observed in children who die in utero from other causes, 
or during extraction after turning, in cases of preternatural presentations. 

Cask XXL— Sept. 29, 1832. Mrs. O'Neil desired me to visit a hospital pa- 
tient, residing in Pump Street, who was flooding. She was in labour of her 
sixth child, but not quite at the end of pregnancy. During the seventh and 
eighth months, she had a slight attack of the same accident, both of which were 
easily arrested by rest in bed, and the external application of cold vinegar and 
water. She had pains for about three hours before I saw her, but they were 
now more frequent and stronger. The discharge, at first trivial, had become 
very profuse. She was rather pale, and felt a little faintish. Her pulse was 
more frequent than natural, but was not very weak. The os uteri was dilated 
to about the size of a crown-piece ; it was soft and yielding. I ascertained that 
the placenta was placed over it, but I could not find its connection with the 
membranes, and therefore I concluded that this organ was nearly (if not) cen- 
trally fixed over the os uteri. One drachm of tincture of opium was taken. 

The local and general condition being favourable for delivery, and the child 
being alive, I concluded to perform this operation, having first had the regu- 
lating bandage put on, so as just to support the uterus, but afterwards to be 
cautiously tightened, as required, during the passage of the child. I now 
passed my hand slowly on, in a conical form, to the os uteri, and endeavoured 
to find the separated portion of the placenta, which (as I thought) I did. In 
carrying my hand onward, I moved it sideways, in opposite directions, so as 
to detach a considerable and an adequate portion of this organ ; during which 
there was an increased discharge of blood. Having ruptured the membranes, 
I easily found a foot of the child, and readily brought it down. After I had 
drawn it so far as to bring the breech of the child, with one thigh bent upon its 
abdomen, to lightly bear on the cervix and os uteri, I rested, so that these por- 
tions of the uterus should not be too rapidly distended, before they were in some 
measure prepared for the passage of a bulk of such magnitude. The hemor- 
rhage had now ceased, and as the child had not advanced so far as to expose 
the funis to dangerous pressure, I waited awhile longer, during which time 
the bandage was kept well tightened, and friction used over it, so as to induce 
uterine action. Shortly a strong pain occurred, when I cautiously drew down 
by the leg, and fortunately the child advanced ; and as the pains continued, I 



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co-operated in slowly extracting, and in the course of a very short time the 
child was born alive. The placenta followed immediately ; on its maternal 
surface were to be seen the signs of the former and more recent separations. 
There was no more bleeding. A drachm of laudanum was given. She went 
on very well until the third day, when she had a slight attack of phlebitis, 
which readily yielded to treatment. 

Remarks. — Both the local and constitutional condition were highly favour- 
able for delivery ; I therefore at once had recourse to it. Although the os and 
cervix uteri were tangibly in such a state of non-resistance to even a moderate 
force, yet I considered it both wiser and safer slowly and cautiously to draw 
down the child after having turned it. Its life, as well as that of the mother, 
would have been hazarded by too rapid extraction. The breech, with one thigh 
bent upwards and lying on the child's belly, is (as I have elsewhere stated) 
nearly equal in its measurement to the head; so that if this part is rapidly 
pulled through the cervix and os uteri before these portions of the uterus are 
prepared (which preparation must be gradually effected to permit its safe pas- 
sage), this forcible distension then produces laceration and contusion of these 
parts, which in some cases has been found nearly in a state of sphacelus. 
Phlebitis and peritonitis not unfrequently occur after this mischievous practice. 

Case XXII. — I am indebted to my respected friend and colleague, Mr. Mas- 
fen, for the following case, in whose words it is cited: — 

" About 8 o'clock on the evening of Feb. 5, 1856, I was called in by Mr. Har- 
ris, to visit Mrs. N., of Silver Street, Hulme, who was stated to be eight 
months pregnant, but who had been in labour for two days, and was flooding 
considerably. On my arrival, I found her looking extremely pale, with feeble 
pulse of about 80, and was told she had lost a great deal of blood, but the he- 
morrhage had ceased ; she had had two half drachms of laudanum, and de- 
scribed herself as tolerably comfortable. I ascertained a placental presentation, 
with the os uteri dilated to the size of a shilling, and there were moderate ute- 
rine pains. I gave her a drachm of laudanum, but as it did not appear to have 
any sedative action upon the uterus, I thought it desirable to hasten the de- 
livery, and plug the vagina till such time as the os should be sufficiently dilated. 
I accordingly introduced a large oval sponge with some difficulty into the va- 
gina, pressed it firmly against the os uteri, and secured it by a T bandage. I 
ordered four half drachms of powdered ergot to be given at intervals of half an 
hour; and having given directions to be sent for if the slightest hemorrhage 
should occur, or as soon as there had been sufficient action to produce dilata- 
tion of the os, I left the house. I was not summoned again till 10 o'clock the 
next morning, when Mrs. Harris informed me that the ergot had produced no 
apparent effect, that the pains had continued slightly through the night, that 
there had been no hemorrhage ; but that on removing the bandage this morn- 
ing, the sponge had come away, and she had immediately sent for me. I found 
the patient much in the same condition as I had left her, with feeble pulse, 
and deadly pallor of countenance. I gave a drachm of laudanum, and the os 
having been fully dilated, proceeded to deliver by turning. This was effected 
in a few minutes without any difficulty, and I ruptured the membranes after I 
had found the foot. The introduction of the hand appeared to give her con- 
siderable pain. The placenta came away in five minutes after the birth of the 
child, and the uterus contracted firmly. At the edge of the placenta, the por- 
tion which had been detached was easily distinguishable, about the size of the 
longitudinal section of a lemon, and on its centre was a darker coloured promi- 
nence, about the size of a walnut, produced by the long continued pressure of 
the os. There was no hemorrhage. I applied a binder myself tightly over 
the abdomen, and the patient expressed herself as feeling very comfortable, 
and much delighted at having got over it so easily. The pulse at this time 
was scarcely perceptible, but it materially improved under the influence of a 
drachm of laudanum, which I ordered to be repeated. I remained in the house 
half an hour after the delivery, and she thought she should go to sleep, but 
complained of the tightness of the binder. It however was not slackened. On 
reaching home, about an hour afterwards, I found an urgent message had been 
left some time before, that I should visit the same patient immediately. I lost 



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no time, but found that all was over. It appears that within five minutes of 
my leaving the house, she was suddenly seized with symptoms of dissolution. 
A neighbouring medical man was called in, but he said nothing was to be done, 
and she did not live many minutes. There had been no more hemorrhage, and 
the uterus, which I examined, was still firmly contracted. 

"This case presents two points worthy of consideration. Would different 
treatment, or would additional treatment, have been attended with a satisfac- 
tory result? As regards the propriety of delivering under such circumstances, 
my friend, Dr. Kadford, I believe, entertains doubts. It appeared to me, how- 
ever, that to leave the patient with symptoms of labour, and an ascertained 
placenta prgevia, would have been attended with imminent danger ; and to have 
stayed an indefinite time, would have been out of the question, as actual labour 
might not have come on without interference for days or weeks. For loss of 
blood simply, I have almost invariably found opium a specific ; and the quan- 
tities of this drug which exsanguined patients will tolerate, is only limited by 
the extent to which the hemorrhage has proceeded. The patient had half an 
ounce of laudanum in fifteen hours ; she would doubtless have borne much 
more, but the symptoms did not appear to require it. The most direct and 
rational remedy — and, I think, the best — for extreme loss of blood, is trans- 
fusion. I performed this operation a few years ago in a somewhat similar case 
(vide Lancet, 1851, vol. i. p. 434) with perfect success. The gradual return of 
the pulse as the process was going on, at first wavering, then permanent, and 
afterwards the return of consciousness and the manifestation of interest in 
what was going on, establish this as a remedy of the highest utility. But 
what is the indication for its necessity ? The patient on whom I performed 
the operation was apparently lifeless, utterly unconscious, and with no pulse 
at the wrist. In this case, the patient, when I left her, was lively and cheer- 
ful, and the pulse was improving under the use of opium. Dr. Kadford speaks 
highly of the use of galva